Dissociation of the pathways mediating ipsilateral and contralateral motor-evoked potentials in human hand and arm muscles

Using paired pulse TMS to facilitate contralateral and ipsilateral MEPs in upper extremity muscles of chronic hemiparetic stroke patients

In moderate to severely impaired stroke patients, single pulse TMS, with or without background facilitation, may not be able to evoke a motor response in muscles of the upper extremity, thereby hindering potential studies of stroke patients using TMS. Paired pulse TMS has been shown to facilitate responses in distal muscles of healthy subjects. In this study, our aim was to investigate thirteen muscles of the upper extremity in moderate to severely impaired stroke patients and determine the paired pulse interstimulus interval (ISI) that was optimal for facilitation of the TMS response.

METHODS

We recruited 8 moderate to severely impaired stroke patients and 5 healthy controls. A hotspot was found that could activate the greatest number of the 13 target upper extremity muscles. 16 ISIs were tested.

RESULTS

In healthy controls, an ISI range of 3-50 ms in the left hemisphere and 8-40 ms in the right hemisphere was optimal for activating the contralateral arm. In the stroke patients, stimulation of the non-lesioned hemisphere at an ISI of 8-50 ms was optimal for contralateral responses, similar to the control subjects, while stimulation of the lesioned hemisphere had an optimal ISI range of 12-50 ms. Ipsilateral responses in the paretic limb were frequent and the optimal ISI range was much later than the contralateral responses in stroke or controls occurring at 25-40 ms.

CONCLUSION

In stroke and control subjects, across muscles and contralateral or ipsilateral pathways, an interstimulus interval of 25-40 ms was optimal to evoke a TMS response and resulted in the greatest degree of facilitation.

Task-dependent differences in corticobulbar excitability of the submental motor projections: Implications for neural control of swallowing

It has been suggested that the primary motor cortex plays a substantial role in the neural circuitry that controls swallowing. Although its role in the voluntary oral phase of swallowing is undisputed, its precise role in motor control of the more reflexive, pharyngeal phase of swallowing is unclear. The contribution of the primary motor cortex to the pharyngeal phase of swallowing was examined using transcranial magnetic stimulation (TMS) to evoke motor evoked potentials (MEPs) in the anterior hyomandibular muscle group during either volitional submental muscle contraction or contraction during the pharyngeal phase of both volitionally, and reflexively, initiated swallowing. For each subject, in all three conditions, TMS was triggered when submental surface EMG (sEMG) reached 75% of the mean maximal submental sEMG amplitude measured during 10 volitional swallows. MEPs recorded during volitional submental muscle contraction were elicited in 22 of the 35 healthy subjects examined (63%). Only 16 of these 22 subjects (45.7%) also displayed MEPs recorded during volitional swallowing, but their MEP amplitudes were larger when triggered by submental muscle contraction than when triggered by volitional swallowing. Additionally, only 7 subjects (of 19 tested) showed MEPs triggered by submental muscle contraction during a reflexively triggered pharyngeal swallow. These differences indicate differing levels of net M1 excitability during execution of the investigated tasks, possibly brought about by task-dependent changes in the balance of excitatory and inhibitory neural activity.

Theta Burst Stimulation of Human Primary Motor Cortex Degrades Selective Muscle Activation in the Ipsilateral Arm

This study investigated whether repetitive transcranial magnetic stimulation (TMS) delivered as continuous theta burst stimulation (cTBS) to left M1 degraded selective muscle activation in the contralateral and ipsilateral upper limb in healthy participants. Contralateral motor-evoked potentials (cMEPs) were elicited in left and right biceps brachii (BB) before either elbow flexion or forearm pronation. A neurophysiological index, the excitability ratio (ER), was computed from the relative size of BB cMEPs before each type of movement. Short interval intracortical inhibition (SICI) was assessed in cMEPs of right BB with paired-pulse TMS of left M1. Ipsilateral MEPs (iMEPs) and silent periods (iSPs) were measured in left BB with single-pulse TMS of left M1. Low-intensity cTBS was expected to suppress corticospinal output from left M1. A sham condition was also included. Real but not sham cTBS caused increases in BB ER bilaterally. In the right arm, ER increased because BB cMEPs before flexion were less facilitated, whereas cMEPs in the pronation task were unaffected. This was accompanied by an increase in left M1 SICI. In the left arm, ER increased because BB cMEPs before pronation were facilitated but were unaffected in the flexion task. There was also facilitation of left BB iMEPs. These changes in the left arm are consistent with inappropriate facilitation of left BB α-motoneurons (αMNs) before pronation. This is the first demonstration that cTBS of M1 can alter excitability of neurons controlling ipsilateral proximal musculature and degrade ipsilateral upper limb motor control, providing evidence that ipsilateral and contralateral M1 shape the spatial and temporal characteristics of proximal muscle activation appropriate for the task at hand.

Handedness, dexterity, and motor cortical representations

Motor system organization varies with handedness. However, previous work has focused almost exclusively on direction of handedness (right or left) as opposed to degree of handedness (strength). In the present study, we determined whether measures of interhemispheric interactions and degree of handedness are related to contra- and ipsilateral motor cortical representations. Participants completed a battery of handedness assessments including both handedness preference measures and behavioral measures of intermanual differences in dexterity, a computerized version of the Poffenberger paradigm (PP) to estimate interhemispheric transfer time (IHTT), and they underwent transcranial magnetic stimulation (TMS) mapping of both motor cortices while we recorded muscle activity from the first dorsal interosseous muscle bilaterally. A greater number of ipsilateral motor evoked potentials (iMEPs) were elicited in less lateralized individuals with the number of iMEPs correlated with IHTT. There were no relationships between handedness or lateralization of dexterity and symmetry of contralateral motor representations, although this symmetry was related to IHTT. Finally, IHTT was positively correlated with multiple measures of laterality and handedness. These findings demonstrate that degree of laterality of dexterity is related to the propensity for exhibiting iMEPs and the speed of interhemispheric interactions. However, it is not clear whether iMEPs are directly mediated via ipsilateral corticospinal projections or are transcallosally transmitted.

Topographical organization of mu and Beta band activity associated with hand and foot movements in patients with perirolandic lesions

To study the topographical organization of mu and beta band event-related desynchronization (ERD) associated with voluntary hand and foot movements, we used magnetoencephalographic (MEG) recordings from 19 patients with perirolandic lesions. Synthetic aperture magnetometry (SAM) was used to detect and localize changes in the mu (7 - 11 Hz) and beta (13 - 30 Hz) frequency bands associated with repetitive movements of the hand and foot and overlaid on individual coregistered magnetic resonance (MR) images. Hand movements showed homotopic and contralateral ERD at the sensorimotor (S/M) cortex in the majority of cases for mu and to a lesser extent for beta rhythms. Foot movements showed an increased heterotopic distribution with bilateral and ipsilateral ERD compared to hand movements. No systematic topographical segregation between mu and beta ERD could be observed. In patients with perirolandic lesions, the mu and beta band spatial characteristics associated with hand movements retain the expected functional-anatomical boundaries to a large extent. Foot movements have altered patterns of mu and beta band ERD, which may give more insight into the differential functional role of oscillatory activity in different voluntary movements.

A method to measure the distribution of latencies of motor evoked potentials in man

OBJECTIVE

To measure the intra-individual distribution of the latencies of motor evoked potentials (MepL) using transcranial magnetic stimulation.

METHODS

We used the triple stimulation technique (TST) to quantify the proportion of excited spinal motor neurons supplying the abductor digiti minimi muscle in response to a maximal magnetic brain stimulus (Magistris et al., 1998). By systematically manipulating the TST delay, we could quantify the contribution of slow-conducting motor tract portions to the TST amplitude.

RESULTS

Our method allowed the establishment of a MepL distribution for each of the 29 examined healthy subjects. MepLs of 50% of the motor tract contributing to the motor evoked potential laid between the intra-individually minimal MepL (MepL(min)) and MepL(min)+4.9 ms (range 1.6-9.2). The individual MepL distributions showed two peaks in most subjects. The first peak appeared at a MepL that was 3.0 ms longer on average (range 0.7-6.0) than MepL(min); the second peak appeared at MepL(min)+8.1 ms on average (range 3.7-13.0).

CONCLUSIONS

Slow-conducting parts of the motor pathway contribute notably to the motor evoked potential. Our data suggest a bimodal distribution of central conduction times, which might possibly relate to different fibre types within the pyramidal tract.

SIGNIFICANCE

We present a non-invasive method to assess slow-conducting parts of the human central motor tract.

Task-Dependent Modulation of Inputs to Proximal Upper Limb Following Transcranial Direct Current Stimulation of Primary Motor Cortex

Cathodal transcranial DC stimulation (c-tDCS) suppresses excitability of primary motor cortex (M1) controlling contralateral hand muscles. This study assessed whether c-tDCS would have similar effects on ipsi- and contralateral M1 projections to a proximal upper limb muscle. Transcranial magnetic stimulation (TMS) of left M1 was used to elicit motor evoked potentials (MEPs) in the left and right infraspinatus (INF) muscle immediately before and after c-tDCS of left M1, and at 20 and 40 min, post-c-tDCS. TMS was delivered as participants preactivated each INF in isolation (left, right) or both INF together (bilateral). After c-tDCS, ipsilateral MEPs in left INF and contralateral MEPs in right INF were suppressed in the left task but not in the bilateral or right tasks, indicative of task-dependent modulation. Ipsilateral silent period duration in the left INF was reduced after c-tDCS, indicative of altered transcallosal inhibition. These findings may have implications for the use of tDCS as an adjunct to therapy for the proximal upper limb after stroke.

Control of wrist position and muscle relaxation by shifting spatial frames of reference for motoneuronal recruitment: possible involvement of corticospinal pathways

It has previously been established that muscles become active in response to deviations from a threshold (referent) position of the body or its segments, and that intentional motor actions result from central shifts in the referent position. We tested the hypothesis that corticospinal pathways are involved in threshold position control during intentional changes in the wrist position in humans. Subjects moved the wrist from an initial extended to a final flexed position (and vice versa). Passive wrist muscle forces were compensated with a torque motor such that wrist muscle activity was equalized at the two positions. It appeared that motoneuronal excitability tested by brief muscle stretches was also similar at these positions. Responses to mechanical perturbations before and after movement showed that the wrist threshold position was reset when voluntary changes in the joint angle were made. Although the excitability of motoneurons was similar at the two positions, the same transcranial magnetic stimulus (TMS) elicited a wrist extensor jerk in the extension position and a flexor jerk in the flexion position. Extensor motor-evoked potentials (MEPs) elicited by TMS at the wrist extension position were substantially bigger compared to those at the flexion position and vice versa for flexor MEPs. MEPs were substantially reduced when subjects fully relaxed wrist muscles and the wrist was held passively in each position. Results suggest that the corticospinal pathway, possibly with other descending pathways, participates in threshold position control, a process that pre-determines the spatial frame of reference in which the neuromuscular periphery is constrained to work. This control strategy would underlie not only intentional changes in the joint position, but also muscle relaxation. The notion that the motor cortex may control motor actions by shifting spatial frames of reference opens a new avenue in the analysis and understanding of brain function.

Convergence of pyramidal and medial brain stem descending pathways onto macaque cervical spinal interneurons

We investigated the control of spinal interneurons by corticospinal and medial brain stem descending tracts in two macaque monkeys. Stimulating electrodes were implanted in the left pyramidal tract (PT), and the right medial longitudinal fasciculus (MLF), which contains reticulospinal, vestibulospinal, and some tectospinal fibers. Single unit discharge was recorded from 163 interneurons in the intermediate zone of the right spinal cord (segmental levels C(6)-C(8)) in the awake state; inputs from descending pathways were assessed from the responses to stimulation through the PT and MLF electrodes. Convergent input from both pathways was the most common finding (71/163 cells); responses to PT and MLF stimulation were of similar amplitude. Interneuron discharge was also recorded while the animal performed a reach and grasp task with the right hand; the output connections of the recorded cells were determined by delivering intraspinal microstimulation (ISMS) at the recording sites. Convergent input from MLF/PT stimulation was also common when analysis was restricted to cells that increased their rate during grasp (14/23 cells) or to cells recorded at sites where ISMS elicited finger or wrist movements (23/57 cells). We conclude that medial brain stem and corticospinal descending pathways have largely overlapping effects on spinal interneurons, including those involved in the control of the hand. This may imply a more important role for the brain stem in coordinating hand movements in primates than commonly assumed; brain stem pathways could contribute to the restoration of function seen after lesions to the corticospinal tract.

Modulation of interhemispheric inhibition by volitional motor activity: an ipsilateral silent period study

Brief interruption of voluntary EMG in a hand muscle by focal transcranial magnetic stimulation (TMS) of the ipsilateral primary motor cortex (M1), the so-called ipsilateral silent period (ISP), is a measure of interhemispheric motor inhibition. However, little is known about how volitional motor activity would modulate the ISP. Here we tested in 30 healthy adults to what extent and under what conditions voluntary activation of the stimulated right M1 by moving the left hand strengthens interhemispheric inhibition as indexed by an enhancement of the ISP area in the maximally contracting right first dorsal interosseous (FDI). Left index finger abduction, already at low levels of contraction, significantly enhanced the ISP compared to left hand at rest. Even imagination of left index finger movement enhanced the ISP compared to rest or mental calculation. This enhancement occurred in the absence of motor-evoked potential amplitude modulation in the left FDI, thus excluding a non-specific contribution from an increase in right M1 corticospinal excitability. Contraction of the left extensor indicis, but not contraction of more proximal left upper limb or left or right lower limb muscles also enhanced the ISP. A reaction time experiment showed that the ISP enhancement developed at a late stage of movement preparation just before or at movement onset. Interhemispheric inhibition of the motor-evoked potential as tested by a bifocal paired-pulse TMS protocol and thought to be mediated via a neuronal circuit different to the ISP was not enhanced when tested under identical motor task conditions. Finally, ISP enhancement by contraction of the left FDI correlated inversely with EMG mirror activity in the right FDI during phasic abductions of the left index finger. Our findings strongly suggest that voluntary M1 activation by real or imagined movement of the contralateral hand increases interhemispheric motor inhibition of the opposite M1. This phenomenon shows substantial topographical, temporal and neuronal circuit specificity, and has functional significance as it probably plays a pivotal role in suppressing mirror activity.

Modulation of cerebellar excitability by polarity-specific noninvasive direct current stimulation

The cerebellum is a crucial structure involved in movement control and cognitive processing. Noninvasive stimulation of the cerebellum results in neurophysiological and behavioral changes, an effect that has been attributed to modulation of cerebello-brain connectivity. At rest, the cerebellum exerts an overall inhibitory tone over the primary motor cortex (M1), cerebello-brain inhibition (CBI), likely through dentate-thalamo-cortical connections. The level of excitability of this pathway before and after stimulation of the cerebellum, however, has not been directly investigated. In this study, we used transcranial magnetic stimulation to determine changes in M1, brainstem, and CBI before and after 25 min of anodal, cathodal, or sham transcranial direct current stimulation (tDCS) applied over the right cerebellar cortex. We hypothesized that anodal tDCS would result in an enhancement of CBI and cathodal would decrease it, relative to sham stimulation. We found that cathodal tDCS resulted in a clear decrease of CBI, whereas anodal tDCS increased it, in the absence of changes after sham stimulation. These effects were specific to the cerebello-cortical connections with no changes in other M1 or brainstem excitability measures. The cathodal effect on CBI was found to be dependent on stimulation intensity and lasted up to 30 min after the cessation of tDCS. These results suggest that tDCS can modulate in a focal and polarity-specific manner cerebellar excitability, likely through changes in Purkinje cell activity. Therefore, direct current stimulation of the cerebellum may have significant potential implications for patients with cerebellar dysfunction as well as to motor control studies.

Comparison of unilateral and bilateral complex finger tapping-related activation in premotor and primary motor cortex

Sixteen healthy right-handed subjects performed a complex finger-tapping task that broadly activates the motor and premotor regions, including primary motor (M1), ventral premotor (PMv), and dorsal premotor (PMd) cortex. This task was performed with the right hand only, left hand only and both hands simultaneously. Behavioral performance and the possibility of mirror movements were controlled through the use of MRI-compatible gloves to monitor finger movements. Using spatially normalized ROIs from the Human Motor Area Template (HMAT), comparisons were made of the spatial extent and location of activation in the left and right motor regions between all three tasks. During unilateral right and left hand tapping, ipsilateral precentral gyrus activation occurred in all subjects, mainly in the PMv and PMd. Ipsilateral M1 activation was less consistent and shifted anteriorly within M1, towards the border of M1 and premotor cortex. Regions of ipsilateral activation were also activated during contralateral and bilateral tasks. Overall, 83%/70%/58% of the ipsilaterally activated voxels in M1/PMd/PMv were also activated during contralateral and bilateral tapping. The mean percent signal change of spatially overlapping activated voxels was similar in PMv and PMd between all three tasks. However, the mean percent signal change of spatially overlapping M1 activation was significantly less during ipsilateral tapping compared with contra- or bilateral tapping. Results suggest that the ipsilateral fMRI activation in unilateral motor tasks may not be inhibitory in nature, but rather may reflect part of a bilateral network involved in the planning and/or execution of tapping in the ipsilateral hand.

Hemisphere Specific Impairments in Reach-to-Grasp Control After Stroke: Effects of Object Size

Background and objective. The authors investigated hemispheric specialization for the visuomotor transformation of grasp preshaping and the coordination between transport and grasp in individuals poststroke. Based on a bilateral model, the authors hypothesized that after unilateral stroke there would be hemisphere-specific deficits revealed by the ipsilesional limb. Methods. Right or left stroke and age- and limb-matched nondisabled participants performed rapid reach-to-grasp of 3 sized objects. The authors quantified grasp preshaping as the correlation between initial aperture velocity and peak aperture, and peak aperture and object diameter. A cross correlation analysis using transport velocity and aperture size was performed to quantify transport-grasp coordination. All statistical tests for hemisphere-specific deficits involved comparisons between each stroke group and the matched nondisabled group. Results. Overall, the right stroke group, but not left stroke group, demonstrated prolonged movement time. For grasp preshaping there was a higher correlation between initial aperture velocity and peak aperture for the right stroke group and a lower correlation between peak aperture and object diameter for the left stroke group. For transport-grasp coordination the correlation between transport velocity and aperture size was higher for the left stroke group and lower for the right stroke group, which also demonstrated a higher standard deviation of time lag. Conclusions. After left stroke, there was deficient scaling of grasp preshaping and stronger transport-grasp coordination. In contrast, after right stroke, grasp preshaping began earlier and transport-grasp coordination was weaker. Together, these hemisphere-specific deficits suggest a left hemisphere specialization for the visuomotor transformation of grasp preshaping and a right hemisphere specialization for transport-grasp coordination.

Congenitally altered motor experience alters somatotopic organization of human primary motor cortex

Human motor development is thought to result from a complex interaction between genes and experience. The well-known somatotopic organization of the primate primary motor cortex (M1) emerges postnatally. Although adaptive changes in response to learning and use occur throughout life, somatotopy is maintained as reorganization is restricted to modifications within major body part representations. We report of a unique opportunity to evaluate the influence of experience on the genetically determined somatotopic organization of motor cortex in humans. We examined the motor "foot" representation in subjects with congenitally compromised hand function and compensatory skillful foot use. Functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) of M1 revealed that the foot was represented in the classical medial foot area of M1 and was several centimetres away in nonadjacent cortex in the vicinity of the lateral "hand" area. Both areas had direct output to the spinal motor neurons innervating foot muscles and were behaviorally relevant because experimental disruption of either area by TMS altered reaction times. We demonstrate a unique, nonsomatotopically organized M1 in humans, which emerged as a function of grossly altered motor behavior from the earliest stages of development. Our results imply that during early motor development experience may play a more critical role in the shaping of genetically determined neural networks than previously assumed.

Unique cortical physiology associated with ipsilateral hand movements and neuroprosthetic implications

BACKGROUND AND PURPOSE

Brain computer interfaces (BCIs) offer little direct benefit to patients with hemispheric stroke because current platforms rely on signals derived from the contralateral motor cortex (the same region injured by the stroke). For BCIs to assist hemiparetic patients, the implant must use unaffected cortex ipsilateral to the affected limb. This requires the identification of distinct electrophysiological features from the motor cortex associated with ipsilateral hand movements.

METHODS

In this study we studied 6 patients undergoing temporary placement of intracranial electrode arrays. Electrocorticographic (ECoG) signals were recorded while the subjects engaged in specific ipsilateral or contralateral hand motor tasks. Spectral changes were identified with regards to frequency, location, and timing.

RESULTS

Ipsilateral hand movements were associated with electrophysiological changes that occur in lower frequency spectra, at distinct anatomic locations, and earlier than changes associated with contralateral hand movements. In a subset of 3 patients, features specific to ipsilateral and contralateral hand movements were used to control a cursor on a screen in real time. In ipsilateral derived control this was optimal with lower frequency spectra.

CONCLUSIONS

There are distinctive cortical electrophysiological features associated with ipsilateral movements which can be used for device control. These findings have implications for patients with hemispheric stroke because they offer a potential methodology for which a single hemisphere can be used to enhance the function of a stroke induced hemiparesis.

Suppression of activity in the forelimb motor cortex temporarily enlarges forelimb representation in the homotopic cortex in adult rats

After forelimb motor cortex (FMC) damage, the unaffected homotopic motor cortex showed plastic changes. The present experiments were designed to clarify the electrophysiological nature of these interhemispheric effects. To this end, the output reorganization of the FMC was investigated after homotopic area activity was suppressed in adult rats. FMC output was compared after lidocaine-induced inactivation (L-group) or quinolinic acid-induced lesion (Q-group) of the contralateral homotopic cortex. In the Q-group of animals, FMC mapping was performed, respectively, 3 days (Q3D group) and 2 weeks (Q2W group) after cortical lesion. In each animal, FMC output was assessed by mapping movements induced by intracortical microstimulation (ICMS) in both hemispheres (hemisphere ipsilateral and contralateral to injections). The findings demonstrated that in the L-group, the size of forelimb representation was 42.2% higher than in the control group (P < 0.0001). The percentage of dual forelimb-vibrissa movement sites significantly increased over the controls (P < 0.0005). The dual-movement sites occupied a strip of the map along the rostrocaudal border between the forelimb and vibrissa representations. This form of interhemispheric diaschisis had completely reversed, with the recovery of the baseline map, 3 days after the lesion in the contralateral FMC. This restored forelimb map showed no ICMS-induced changes 2 weeks after the lesion in the contralateral FMC. The present results suggest that the FMCs in the two hemispheres interact continuously through predominantly inhibitory influences that preserve the forelimb representation and the border vs. vibrissa representation.

Theta burst stimulation induces after-effects on contralateral primary motor cortex excitability in humans

Interhemispheric interactions between the primary motor cortices (M1) have been described with a variety of TMS methods. Here we give a detailed description of the interhemispheric interactions of a period of theta burst simulation (TBS), a rapid method of producing long lasting after-effects on the excitability of the stimulated M1. A total of 18 right handed healthy subjects participated. In most experiments, continuous and intermittent TBS (cTBS and iTBS) were delivered over the right M1 using a coil orientated to induce antero-posterior followed by postero-anterior (AP-PA) currents in the brain. The intensity of stimulation was 80% of active motor threshold (AMT), and a total of 600 pulses were applied. The effects on the amplitude of motor evoked potentials (MEPs), short interval intracortical inhibition (SICI) and intracortical facilitation (ICF) were evaluated in the left and right M1 before and at three different times after TBS. We also tested long-interval intracortical inhibition (LICI) in right M1 and interhemispheric inhibition (IHI) from right to left M1. Finally, to explore the effect of different polarities of cTBS over dominant and non-dominant hemisphere we delivered AP-PA and postero-anterior followed by antero-posterior (PA-AP) cTBS over either right or left M1 and tested MEPs in both hemispheres. In the stimulated hemisphere, cTBS reduced MEPs and SICI whereas iTBS increased MEPs and SICI. In the non-stimulated hemisphere cTBS increased MEPs and reduced SICI, while iTBS reduced MEPs and increased SICI. There were no effects on ICF, LICI or IHI. Although both AP-PA cTBS and PA-AP cTBS reduced MEPs in the stimulated M1, the former increased MEPs from non-stimulated M1 whereas the latter did not. There was no difference in the effect of cTBS on the dominant or non-dominant hemisphere.

Motor-evoked potentials recorded from lumbar erector spinae muscles: a study of corticospinal excitability changes associated with spinal manipulation

OBJECTIVE

The purpose of this study was to determine if high-velocity, low-amplitude spinal manipulation (SM) altered the effects of corticospinal excitability on motoneuron activity innervating the paraspinal muscles. In a previous study using transcranial magnetic stimulation (TMS), augmentation of motor-evoked potentials (MEPs) from the gastrocnemius muscle after lumbar SM was reported. To date, there is no known report of the effect of SM on paraspinal muscle excitability.

METHODS

The experimental design was a prospective physiologic evaluation of the effects of SM on corticospinal excitability in asymptomatic subjects. The TMS-induced MEPs were recorded from relaxed lumbar erector spinae muscles of 72 asymptomatic subjects. The MEP amplitudes were evaluated pre-SM and post-SM or conditions involving prethrust positioning and joint loading or control.

RESULTS

There was a transient increase in MEP amplitudes from the paraspinal muscles as a consequence of lumbar SM (F([6,414]) = 8.49; P < .05) without concomitant changes after prethrust positioning and joint loading or in control subjects (P > .05). These data findings were substantiated by a significant condition x time interaction term (F([12,414]) = 2.28; P < .05).

CONCLUSIONS

These data suggest that there is a postsynaptic facilitation of alpha motoneurons and/or corticomotoneurons innervating paraspinal muscles as a consequence of SM. It appears that SM may offer unique sensory input to the excitability of the motor system as compared to prethrust positioning and joint loading and control conditions.

Cortical control of erector spinae muscles during arm abduction in humans

Abduction of one arm preferentially activates erector spinae muscles on the other side to stabilise the body. We hypothesise that the corticospinal drive to the arm abductors and the erector spinae may originate from the same hemisphere. In 18 subjects, transcranial magnetic stimulation (TMS) was applied using an angle double-cone coil placed symmetrically over the vertex. Motor evoked potentials (MEP) could not be evoked systematically seated at rest but could be evoked bilaterally in erector spinae muscles during unilateral arm abduction. TMS was applied at 110% and 120% motor threshold (MT) for the contralateral erector spinae muscle when an arm was abducted against resistance. The electromyographic (EMG) activity in the erector spinae at L4 vertebral level during contralateral arm abduction was significantly higher (P<0.05) than in the ipsilateral erector spinae. The mean (+/-S.E.M.) latencies of MEPs in the contralateral muscle to TMS at 120%MT (left 16.0+/-0.8 ms; right 17.0+/-0.8 ms) were significantly (P<0.05) longer than in the ipsilateral erector spinae (13.9+/-1.0 ms; 16.6+/-0.4 ms). In two of six subjects from the same group, it was possible to elicit MEPs by TMS applied selectively to one hemisphere using a figure-of-eight coil. MEPs ipsilateral to the TMS had longer latencies than contralateral MEPs. The study revealed an unexpectedly longer rather than shorter latency of the MEP recorded from the lumbar erector spinae muscles when co-activated during abduction of the opposite arm. A speculative explanation is that TMS might activate back muscles contralateral to arm abduction via an uncrossed, ipsilateral corticospinal tract that is slower conducting than the conventional crossed corticospinal tract. The study has implications for the design of measures to promote recovery and rehabilitation of motor function in disorders such as stroke and spinal cord injury.

Ipsilateral versus contralateral cortical motor projections to a shoulder adductor in chronic hemiparetic stroke: implications for the expression of arm synergies

An increase in ipsilateral descending motor pathway activity has been reported following hemiparetic stroke. In axial muscles, increased ipsilateral cortical activity has been correlated with good recovery whereas in distal arm muscles it is correlated with poor recovery. Currently, little is known about the control of proximal upper limb muscles following stroke. This muscle group is less impaired than the distal arm muscles following stroke, yet contributes to the abnormal motor coordination patterns associated with movements of the arm which can severely impair reaching ability. This study used transcranial magnetic stimulation (TMS) to evaluate the presence and magnitude of ipsilateral and contralateral projections to the pectoralis major (PMJ) muscle in stroke survivors. A laterality index (LI) was used to investigate the relationship between ipsilateral and contralateral projections and strength, clinical impairment level, and the degree of abnormal coordination expressed in the arm. The ipsilateral and contralateral hemispheres were stimulated using 90% TMS intensity while the subject generated shoulder adduction torques in both arms. Motor evoked potentials (MEPs) were measured in the paretic and non-paretic PMJ. The secondary torque at the elbow was measured during maximal adduction as an indicator of the degree of extensor synergy. Ipsilateral MEPs were most common in stroke survivors with moderate to severe motor deficits. The LI was correlated with clinical impairment level (P = 0.05) and the degree of extension synergy expressed in the arm (P = 0.03). The LI was not correlated with strength. These results suggest that increased excitability of ipsilateral pathways projecting to the proximal upper arm may contribute to the expression of the extension synergy following stroke. These findings are discussed in relation to a possible unmasking or upregulation of oligosynaptic cortico-bulbospinal pathways following stroke.

Functional BOLD MRI: comparison of different field strengths in a motor task

The purpose was to evaluate the benefit of an increased field strength for functional magnetic resonance imaging in a motor task. Six right-handed volunteers were scanned at 1.5 T and 3.0 T using a motor task. Each experiment consisted of two runs with four activation blocks, each with right- and left-hand tapping. Analysis was done using BrainVoyagerQX. Differences between both field strengths concerning signal to noise (SNR), blood oxygen level-dependent (BOLD) signal change, functional sensitivity and BOLD contrast to noise (CNR) were tested using a paired t test. Delineation of activations and artifacts were graded by two independent readers. Results were further validated by means of a phantom study. The sensorimotor and premotor cortex, the supplementary motor area, subcortical and cerebellar structures were activated at each field strength. Additional activations of the right premotor cortex and right superior temporal gyrus were found at 3.0 T. Signal-to-noise, percentage of BOLD signal change, BOLD CNR and functional sensitivity improved at 3.0 T by a factor of up to 2.4. Functional imaging at 3.0 T results in detection of additional activated areas, increased SNR, BOLD signal change, functional sensitivity and BOLD CNR.

Imaging the human motor system's beta-band synchronization during isometric contraction

Rhythmic synchronization likely subserves interactions among neuronal groups. One of the best studied rhythmic synchronization phenomena in the human nervous system is the beta-band (15-30 Hz) synchronization in the motor system. In this study, we imaged structures across the human brain that are synchronized to the motor system's beta rhythm. We recorded whole-head magnetoencephalograms (MEG) and electromyograms (EMG) of left/right extensor carpi radialis muscle during left/right wrist extension. We analyzed coherence, on the one hand between the EMG and neuronal sources in the brain, and on the other hand between different brain sources, using a spatial filtering approach. Cortico-muscular coherence analysis revealed a spatial maximum of coherence to the muscle in motor cortex contralateral to the muscle in accordance with earlier findings. Moreover, by applying a two-dipole source model, we unveiled significantly coherent clusters of voxels in the ipsilateral cerebellar hemisphere and ipsilateral cerebral motor regions. The spatial pattern of coherence to the right and left arm EMG was roughly mirror reversed across the midline, in agreement with known physiology. Subsequently, we analyzed the brain-wide pattern of beta-band coherence to the motor cortex contralateral to the contracting muscle. This analysis did not reveal any convincing pattern. Because the prior cortico-muscular analysis had demonstrated the expected pattern in our data, this negative finding demonstrates a current limitation of the applied method for cortico-cortical coherence analysis. We conclude that during an isometric muscle contraction, several distributed brain regions form a brain-wide beta-band network for motor control.

Transcranial magnetic stimulation in children

Developmental disabilities (e.g. attention deficit disorder; cerebral palsy) are frequently associated with deviations of the typical pattern of motor skill maturation. Neurophysiologic tools, such as transcranial magnetic stimulation (TMS), which probe motor cortex function, can potentially provide insights into both typical neuromotor maturation and the mechanisms underlying the motor skill deficits in children with developmental disabilities. These insights may set the stage for finding effective interventions for these disorders. We review the literature pertaining to the use of TMS in pediatrics. Most TMS-evoked parameters show age-related changes in typically developing children and some of these are abnormal in a number of childhood-onset neurological disorders. Although no TMS-evoked parameters are diagnostic for any disorder, changes in certain parameters appear to reflect disease burden or may provide a measure of treatment-related improvement. Furthermore, TMS may be especially useful when combined with other neurophysiologic modalities (e.g. fMRI). However, much work remains to be done to determine if TMS-evoked parameters can be used as valid and reliable biomarkers for disease burden, the natural history of neurological injury and repair, and the efficacy of pharmacological and rehabilitation interventions.

Mapping the cortical representation of the lumbar paravertebral muscles

OBJECTIVE

The aim of this study was to map the cortical representation of the lumbar spine paravertebral (LP) muscles in healthy subjects.

METHODS

Transcranial magnetic stimulation (TMS) was employed to map the cortical representations of the LP muscles at two sites. Stimuli were applied to points on a grid representing scalp positions. The amplitude of motor evoked potentials (n=6) was averaged for each position.

RESULTS

The optimal site for evoking responses in the contralateral LP muscles was situated 1cm anterior and 4 cm lateral to the vertex. Ipsilateral responses were evoked from sites lateral to the optimal site for evoking contralateral responses. Contralateral responses were also obtained from areas anterior to the optimal site.

CONCLUSIONS

Maps of these muscles can be produced. The results suggest discrete contra- and ipsilateral cortical projections. Anterior sites at which excitation can be evoked may indicate projections arising in the SMA are involved.

SIGNIFICANCE

This study provides normative data regarding the cortical representation of the paravertebral muscles and provides a technique for evaluating cortical motor plasticity in patients presenting with spinal pathologies.

Motor cortical measures of use-dependent plasticity are graded from distal to proximal in the human upper limb

In humans, it is well established that practicing simple, repetitive movements with the distal upper limb induces short-term plasticity in the neural pathways that control training. It is unknown how the neural response to similar training at more proximal joints differs. The purpose of this study was to quantify how ballistic training at proximal and distal upper limb joints influences measures of corticomotor plasticity. To accomplish this goal, we had subjects repetitively practice simple movements for 30 min using the index finger, wrist, or elbow. Before and after training, transcranial magnetic stimulation (TMS) was used to activate the corticomotor pathways innervating the trained joint. We assessed the effect of training by quantifying changes in TMS-elicited joint movements and motor-evoked potentials in the training agonists and antagonists. These measures of training-induced neural plasticity were graded from distal to proximal in the upper limb. Training had the greatest immediate effect on the pathways controlling the index finger and this effect decreased for more proximal joints. Our results suggest that the relative sizes and properties of the cortical areas controlling the proximal and distal upper limb influence the effect of training on the corticomotor pathways. These results have implications for how training influences the neural pathways controlling movement in the proximal and distal portions of the human upper limb and the degree to which these effects can be quantified using TMS.

Effect of corpus callosum damage on ipsilateral motor activation in patients with multiple sclerosis: a functional and anatomical study

Functional MRI (fMRI) studies have shown increased activation of ipsilateral motor areas during hand movement in patients with multiple sclerosis (MS). We hypothesized that these changes could be due to disruption of transcallosal inhibitory pathways. We studied 18 patients with relapsing-remitting MS. Conventional T1- and T2-weighted images were acquired and lesion load (LL) measured. Diffusion tensor imaging (DTI) was performed to estimate fractional anisotropy (FA) and mean diffusivity (MD) in the body of the corpus callosum (CC). fMRI was obtained during a right-hand motor task. Patients were studied to evaluate transcallosal inhibition (TCI, latency and duration) and central conduction time (CCT). Eighteen normal subjects were studied with the same techniques. Patients showed increased MD (P < 0.0005) and reduced FA (P < 0.0005) in the body of the CC. Mean latency and duration of TCI were altered in 12 patients and absent in the others. Between-group analysis showed greater activation in patients in bilateral premotor, primary motor (M1), and middle cingulate cortices and in the ipsilateral supplementary motor area, insula, and thalamus. A multivariate analysis between activation patterns, structural MRI, and neurophysiological findings demonstrated positive correlations between T1-LL, MD in the body of CC, and activation of the ipsilateral motor cortex (iM1) in patients. Duration of TCI was negatively correlated with activation in the iM1. Our data suggest that functional changes in iM1 in patients with MS during a motor task partially represents a consequence of loss of transcallosal inhibitory fibers.

Interhemispheric and ipsilateral connections in Parkinson's disease: relation to mirror movements

Mirror movements (MM) occur in early, asymmetric Parkinson's disease (PD). To examine the pathophysiology of MM in PD, we studied 13 PD patients with MM (PD-MM), 7 PD patients without MM (PD-NM), and 14 normal subjects. Cross-correlogram did not detect common synaptic input to motoneuron pools innervating homologous hand muscles in PD-MM patients. Transcranial magnetic stimulation studies showed no significant difference in ipsilateral motor-evoked potentials between PD-MM patients and normal subjects. The MM side of PD-MM patients showed a slower increase in ipsilateral silent period area with higher level of muscle contraction than the non-MM side and normal subjects. There was less interhemispheric inhibition (IHI) at long interstimulus intervals of 20 to 50 ms in PD-MM than PD-NM. IHI reduced short interval intracortical inhibition in normal subjects and PD-NM, but not in PD-MM. IHI significantly increased intracortical facilitation in PD-MM and PD-NM patients, but not in normal subjects. Our results suggest that MM in PD is due to activation of the contralateral motor cortex. PD-MM patients had reduced transcallosal inhibitory effects on cortical output neurons and on intracortical inhibitory circuits compared to PD-NM patients and controls. These deficits in transcallosal inhibition may contribute to MM in PD patients.

Reorganisation of the somatosensory system after early brain damage

OBJECTIVE

To examine the reorganisation of the somatosensory system after early brain lesions.

METHODS

We studied 12 young patients with congenital hemiplegia. Causative lesions were brain malformations, periventricular injuries and cortico-subcortical lesions. We explored the somatosensory system using evoked potentials, fMRI during sensory stimulation and clinical assessment of sensory function. To correlate sensory and motor function, we also performed transcranial magnetic stimulation, fMRI of hand movement and assessment of motor function by means of Melbourne test.

RESULTS

Eleven patients showed a perilesional reorganisation of primary somatosensory function, as expressed by short latency potentials following stimulation of the paretic hand; in a remaining patient, delayed latency responses (N27.1) were only elicited over the ipsilateral undamaged hemisphere. Five of the eleven patients with perilesional somatosensory representation of the affected hand showed contralesional shifting of motor function, thus exhibiting sensory-motor dissociation. Significant correlation was found between sensory deficit and fMRI activation during sensory stimulation.

CONCLUSIONS

In subjects with early brain lesions, somato-sensory function is generally reorganised within the affected hemisphere. A contralesional shifting is uncommon and poorly efficient in function restoration.

SIGNIFICANCE

This study confirms and further explores the difference in reorganisation capabilities of the motor and sensory system following early brain injury of different etiologies and timing.

The effects of age and attention on motor overflow production—A review

Motor overflow refers to overt involuntary movement, or covert muscle activity, that sometimes co-occurs with voluntary movement. Various clinical populations exhibit overflow. Motor overflow is also present in healthy children and the elderly, although in young adults, overt overflow is considered abnormal unless elicited under conditions of extreme force or muscle fatigue. Current theories of overflow imply that the corpus callosum may mediate production of this phenomenon. However, given that the corpus callosum is a conduit enabling the transfer of cortical information, surprisingly few studies have considered the cortical or subcortical structures underlying overflow. This review considers the developmental trend of motor overflow production, specifically in the upper-limbs, and the mechanisms thought to underlie this age-related phenomenon. Potential neurological correlates of motor overflow will be discussed in conjunction with higher order attentional processes which also regulate motor overflow production. Future research investigating the impact of attentional processes on overflow production may be particularly valuable for designing rehabilitation strategies for patients experiencing induced pathological overflow or conversely, to develop techniques to encourage the recovery of movement function in individuals with paretic limbs.

Interhemispheric interactions and redundancy gain: tests of an interhemispheric inhibition hypothesis

In simple reaction time (RT) tasks, responses are faster when stimuli are presented to both the left and right visual hemifields than when a stimulus is presented to a single hemifield. Paradoxically, this redundancy gain with bilateral stimuli is enhanced in split-brain individuals relative to normals. This article reports three experiments testing an account of that enhancement in which normals' responses to bilateral stimuli are slowed by interhemispheric inhibition. In simple RT tasks, normal participants responded bimanually to left, right, or bilateral visual stimuli. In choice RT tasks, they responded to each stimulus with one hand, responding bimanually only when both stimuli were presented. Measurements of response forcefulness (Experiment 1) and electroencephalographic activity (Experiments 2 and 3) showed no evidence of the correlation patterns predicted by the hypothesis of interhemispheric inhibition. The results suggest that such inhibition is unlikely to be the explanation for enhanced redundancy gain in split-brain individuals.

Ipsilateral motor activation during unimanual and bimanual motor tasks

OBJECTIVE

To test for the presence and possible asymmetry of ipsilateral motor activation during unimanual and bimanual motor tasks.

METHODS

Twelve right-handed healthy subjects underwent motor evoked potential (MEP) measurement of one hand (target-hand) while the other hand (task-hand) performed different motor tasks. The target-hand was either at rest (first experiment) or performed a Perdue PegBoard task (second experiment). The task-hand was either at rest, performed a simultaneous pegboard task, or rotated a coin (second experiment).

RESULTS

In the first experiment, the motor task resulted in significant increase in MEP area in the target-hand, regardless which hand was the task-hand, with a greater increase when the left hand was the task-hand. In the second experiment, ipsilateral motor activation was not present for either hand, however, when the right hand was the task-hand, performance of continuous coin rotation by the right hand resulted in a significant decrease in the MEP area of the left hand.

CONCLUSIONS

Hemispheric asymmetry and task-dependence of ipsilateral motor cortex activation supports the postulate that motor activity may start bilaterally with subsequent interhemispheric inhibition. Furthermore, in right-handers, the left motor cortex is either more active in ipsilateral hand movements or exerts more effective inhibitory control over the right motor cortex than vice versa.

SIGNIFICANCE

We suggest that hemispheric asymmetry in ipsilateral motor control is a factor in determining motor dominance in right-handed individuals.

Transcallosal inhibition in amyotrophic lateral sclerosis

OBJECTIVE

Assessment of upper motor neuron (UMN) involvement is essential for the diagnosis of amyotrophic lateral sclerosis (ALS). In a number of ALS cases, mirror movements (MM) suggest an involvement of transcallosal fibre tracts in conjunction with UMN involvement. The present study analysed whether deficient transcallosal inhibition (TI) tested by TMS enables detection of cortical affection in ALS, even at early stages of the disease.

METHODS

In three patients with definite ALS and 12 patients with early ALS (aged 64.1+/-7.8 years) TMS investigation included analysis of contralateral (cMEP) and ipsilateral (iMEP) motor evoked potentials as well as measurement of TI (latency, duration) with recording from both first dorsal interosseus muscles.

RESULTS

Clinical UMN signs were present in four patients. 83.3% of patients showed a pathological TI (prolongation or loss of TI). Five out of eight ALS patients showing a pathological TI had no clinical UMN signs. Two of these patients showed MM. One patient displayed also pathological findings in TI investigation.

CONCLUSIONS

Our findings suggest a functional deficit of transcallosal fibre tracts even at early stages of the disease still lacking clinical UMN signs.

SIGNIFICANCE

Measurement of TI tested by TMS can detect an involvement of the cortical output system in ALS and may be helpful in an early assessment of the diagnosis.

Differences of the ipsilateral silent period in small hand muscles

The ipsilateral silent period (iSP) is thought to depend on activity transmitted by the corpus callosum but ipsilateral corticospinal pathways may also contribute. Because the presence of ipsilateral corticospinal pathways differs between small hand muscles, we compared the iSP in the first dorsal interosseous (FDI) and abductor pollicis brevis (APB) muscles. The iSP was elicited in 20 healthy subjects by focal transcranial magnetic stimulation of one primary motor cortex during maximal voluntary contraction of the ipsilateral target muscle. The iSP duration was significantly longer in the FDI than APB because of an irregularly occurring second phase of inhibition in the FDI that was absent in the APB. Although the first phase of inhibition is transmitted by the corpus callosum, we provide evidence that the second phase is mediated through ipsilateral corticospinal pathways. Therefore, for specific assessment of callosal conduction, the iSP should be measured in the APB rather than FDI.

Ipsilateral corticospinal projections do not predict congenital mirror movements: a case report

Congenital mirror movements (CMMs) are involuntary, symmetric movements of one hand during the production of voluntary movements with the other. CMMs have been attributed to a range of physiological mechanisms, including excessive ipsilateral projections from each motor cortex to distal extremities. We examined this hypothesis with an individual showing pronounced CMMs. Mirror movements were characterized for a set of hand muscles during a simple contraction task. Transcranial magnetic stimulation (TMS) was then used to map the relative input to each muscle from both motor cortices. Contrary to our expectations, CMMs were most prominent for muscles with the strongest contralateral representation rather than in muscles that were activated by stimulation of either hemisphere. These findings support a bilateral control hypothesis whereby CMMs result from the recruitment of both motor cortices during intended unimanual movements. Consistent with this hypothesis, bilateral motor cortex activity was evident during intended unimanual movements in an fMRI study. To assess the level at which bilateral recruitment occurs, motor cortex excitability during imagined unimanual movements was assessed with TMS. Facilitory excitation was only observed in the contralateral motor cortex. Thus, the bilateral recruitment of the hemispheres for unilateral actions in individuals with CMMs appears to occur during movement execution rather than motor planning.

Motor cortex excitability during unilateral muscle activity

The effect of unilateral tonic muscle activity with and without co-activation of the antagonists on motor cortex excitability has been studied. Motor evoked potentials (MEPs) were recorded from the first dorsal interosseus muscles of both hands in response to transcranial magnetic stimulation (TMS) during relax, isometric index finger abduction and antagonistic co-activation. The intracortical inhibition (ICI) and intracortical facilitation (ICF) were investigated by paired-pulse TMS with interstimulus intervals of 3 and 13 ms. The unilateral tonic activation of the right hand facilitated contralateral and ipsilateral responses (cMEP and iMEP) recorded from both hands with an exception of iMEPs recorded from the left hand. During paired-pulse TMS ICI for cMEPs was not influenced by the unilateral tonic activity in both hands, while ICF was suppressed when MEPs were recorded from the active right hand. The effect of unilateral tonic activity on iMEP in response to paired-pulse TMS was essentially different: generally, ICI was greater for iMEPs and ICF was completely abolished with an exception of iMEPs recorded from the left hand during right finger isometric abduction when a strong ICF was evident. The decreased ICF and/or increased ICI are assumed to reflect mechanisms underlying the co-activation of antagonists.

The origin of activity in the biceps brachii muscle during voluntary contractions of the contralateral elbow flexor muscles

During strong voluntary contractions, activity is not restricted to the target muscles. Other muscles, including contralateral muscles, often contract. We used transcranial magnetic stimulation (TMS) to analyse the origin of these unintended contralateral contractions (termed "associated" contractions). Subjects (n = 9) performed maximal voluntary contractions (MVCs) with their right elbow-flexor muscles followed by submaximal contractions with their left elbow flexors. Electromyographic activity (EMG) during the submaximal contractions was matched to the associated EMG in the left biceps brachii during the right MVC. During contractions, TMS was delivered to the motor cortex of the right or left hemisphere and excitatory motor evoked potentials (MEPs) and inhibitory (silent period) responses recorded from left biceps. Changes at a spinal level were investigated using cervicomedullary stimulation to activate corticospinal paths (n = 5). Stimulation of the right hemisphere produced silent periods of comparable duration in associated and voluntary contractions (218 vs 217 ms, respectively), whereas left hemisphere stimulation caused a depression of EMG but no EMG silence in either contraction. Despite matched EMG, MEPs elicited by right hemisphere stimulation were approximately 1.5-2.5 times larger during associated compared to voluntary contractions (P < 0.005). Similar inhibition of the associated and matched voluntary activity during the silent period suggests that associated activity comes from the contralateral hemisphere and that motor areas in this (right) hemisphere are activated concomitantly with the motor areas in the left hemisphere. Comparison of the MEPs and subcortically evoked potentials implies that cortical excitability was greater in associated contractions than in the matched voluntary efforts.

Electromyographic analysis of joint-dependent global synkinesis in the upper limb of healthy adults: Laterality of intensity and symmetry of spatial representation

The intensity and spatial representation of electromyographical (EMG) activity were examined to characterize the effects of limb dominance and movement direction upon global synkinesis (GS). Twenty-two healthy young subjects (11 men, 11 women) with a mean age of 24.7 years participated in this study. Three trials of EMG activities from eight primary muscles in the unexercised limb were recorded when a maximal isometric contraction in various directions was performed by the shoulder, elbow, and wrist of the dominant and non-dominant upper limbs. The features of GS, including intensity and spatial representation, were quantified with standardized net excitation levels (SNE) and relative excitation (RE), respectively. Our data indicated that (1) GS intensity was strongly limb-dependent with a larger SNE level arising when target joints of the non-dominant upper limb were active, (2) the GS intensity was more influenced by movement direction of the non-dominant limb than by that of the dominant limb, (3) the gradient change in GS intensity was observed bilaterally with a larger SNE level associated with contralateral movements of a proximal joint than a distal joint, and (4) GS spatial representations of the upper limbs were patterned and symmetrical, but seemly insensitive to movement direction. Laterality in GS intensity and structured GS spatial representation with symmetry could be a consequence of use-dependent hemispheric organization.

Sensorimotor organization in double cortex syndrome

Subcortical band heterotopia is a diffuse malformation of cortical development related to pharmacologically intractable epilepsy. On magnetic resonance imaging (MRI), patients with "double cortex" syndrome (DCS) present with a band of heterotopic gray matter separated from the overlying cortex by a layer of white matter. The function and connectivity of the subcortical heterotopic band in humans is only partially understood. We studied six DCS patients with bilateral subcortical band heterotopias and six healthy controls using functional MRI (fMRI). In controls, simple motor task elicited contralateral activation of the primary motor cortex (M1) and ipsilateral activation of the cerebellum and left supplementary motor area (SMA). All DCS patients showed task-related contralateral activation of both M1 and the underlying heterotopic band. Ipsilateral motor activation was seen in 4/6 DCS patients. Furthermore, there were additional activations of nonprimary normotopic cortical areas. The sensory stimulus resulted in activation of the contralateral primary sensory cortex (SI) and the thalamus in all healthy subjects. The left sensory task also induced a contralateral activation of the insular cortex. Sensory activation of the contralateral SI was seen in all DCS patients and secondary somatosensory areas in 5/6. The heterotopic band beneath SI became activated in 3/6 DCS patients. Activations were also seen in subcortical structures for both paradigms. In DCS, motor and sensory tasks induce an activation of the subcortical heterotopic band. The recruitment of bilateral primary areas and higher-order association normotopic cortices indicates the need for a widespread network to perform simple tasks.

The role of multiple contralesional motor areas for complex hand movements after internal capsular lesion

Imaging techniques document enhanced activity in multiple motor areas of the damaged and contralesional (intact) hemisphere (CON-H) after stroke. In the subacute stage, increased activity within motor areas in the CON-H during simple movements of the affected hand has been shown to correlate with poorer motor outcome. For those patients in the chronic stage who recovered well, the functional relevance of an increased activation within the CON-H is unclear. Using trains of repetitive transcranial magnetic stimulation (TMS) during performance of complex finger movements, we tested the behavioral relevance of regional functional magnetic resonance imaging (fMRI) activation within the CON-H for sequential finger movement performance of the recovered hand in seven patients who had experienced a subcortical stroke. TMS was navigated over fMRI activation maxima within anatomically preselected regions of the CON-H, and effects were compared with those of healthy controls. Stimulation over the dorsal premotor cortex (dPMC), the primary motor cortex (M1), and the superior parietal lobe (SPL) resulted in significant interference with recovered performance in patients. Interference with the dPMC and M1 induced timing errors only, SPL stimulation caused both timing and accuracy deficits. The present results argue for a persistent beneficial role of the dPMC, M1, and SPL of the CON-H on some aspects of effectively recovered complex motor behavior after subcortical stroke.

Post-lesional cerebral reorganisation: evidence from functional neuroimaging and transcranial magnetic stimulation

Reorganisation of cerebral representations has been hypothesised to underlie the recovery from ischaemic brain infarction. The mechanisms can be investigated non-invasively in the human brain using functional neuroimaging and transcranial magnetic stimulation (TMS). Functional neuroimaging showed that reorganisation is a dynamic process beginning after stroke manifestation. In the acute stage, the mismatch between a large perfusion deficit and a smaller area with impaired water diffusion signifies the brain tissue that potentially enables recovery subsequent to early reperfusion as in thrombolysis. Single-pulse TMS showed that the integrity of the cortico-spinal tract system was critical for motor recovery within the first four weeks, irrespective of a concomitant affection of the somatosensory system. Follow-up studies over several months revealed that ischaemia results in atrophy of brain tissue adjacent to and of brain areas remote from the infarct lesion. In patients with hemiparetic stroke activation of premotor cortical areas in both cerebral hemispheres was found to underlie recovery of finger movements with the affected hand. Paired-pulse TMS showed regression of perilesional inhibition as well as intracortical disinhibition of the motor cortex contralateral to the infarction as mechanisms related to recovery. Training strategies can employ post-lesional brain plasticity resulting in enhanced perilesional activations and modulation of large-scale bihemispheric circuits.

Corticomotor excitability during a choice-hand reaction time task

Fourteen neurologically healthy, right-handed subjects performed a choice-hand reaction time (RT) task, which involved wrist flexion or extension of either the left or right hand to one of three fixed target locations corresponding to 45 degrees flexion, 20 degrees flexion, or 20 degrees extension from the starting position. In each trial, a pre-cue provided information regarding the forthcoming target location. The hand was specified by the imperative signal. Focal transcranial magnetic stimulation (TMS) was delivered over the hand motor area of either the right or left hemisphere at set times during the foreperiod, and at random intervals during the RT interval defined by electromyography onset. As expected, an increase in corticomotor excitability was observed in the agonist of the responding hand over the RT interval. When the cue appeared at a location that required flexion with either hand, an increase in excitability was observed following stimulation over the hemisphere ipsilateral to the responding hand, indicating activation of the homologous muscle. However, when the cue appeared at a location at which the response would require flexion with one hand and extension with the other, the modulation of excitability was also based on the direction of the response. This direction-specific effect was only observed for TMS delivered to the left hemisphere during the left-hand movement, and suggested goal-based preparation in the left hemisphere independent of whether the actual movement is made with the right or left hand. These results indicate that both the homologous-muscle and the directional-specific constraints affect the corticomotor excitability of the non-responding hand.

Modulatory effects of high-frequency repetitive transcranial magnetic stimulation on the ipsilateral silent period

In healthy subjects, suprathreshold repetitive transcranial magnetic stimulation (rTMS) at frequencies >2 Hz prolongs the cortical silent period (CSP) over the course of the train. This progressive lengthening probably reflects temporal summation of the inhibitory interneurons in the stimulated primary motor cortex (M1). In this study, we tested whether high-frequency rTMS also modulates the ipsilateral silent period (ISP). In nine normal subjects, suprathreshold 10-pulse rTMS trains were delivered to the right M1 at frequencies of 3, 5, and 10 Hz during maximal isometric contraction of both first dorsal interosseous muscles. At 10 Hz, the second pulse of the train increased the area of the ISP; the other stimuli did not increase it further. During rTMS at 3 and 5 Hz, the ISP remained significantly unchanged. Control experiments showed that 10-Hz rTMS delivered at subthreshold intensity also increased the ISP. rTMS over the hand motor area did not facilitate ISPs in the biceps muscles. Finally, rTMS-induced ISP facilitation did not outlast the 10-Hz rTMS train. These findings suggest that rTMS at a frequency of 10 Hz potentiates the interhemispheric inhibitory mechanisms responsible for the ISP, partly through temporal summation. The distinct changes in the ISP and CSP suggest that rTMS facilitates intrahemispheric and interhemispheric inhibitory phenomena through separate neural mechanisms. The ISP facilitation induced by high-frequency rTMS is a novel, promising tool to investigate pathophysiological abnormal interhemispheric inhibitory transfer in various neurological diseases.

Multimodal imaging of brain reorganization in motor areas of the contralesional hemisphere of well recovered patients after capsular stroke

Clinical recovery after stroke can be significant and has been attributed to plastic reorganization and recruitment of novel areas previously not engaged in a given task. As equivocal results have been reported in studies using single imaging or electrophysiological methods, here we applied an integrative multimodal approach to a group of well-recovered chronic stroke patients (n = 11; aged 50-81 years) with left capsular lesions. Focal activation during recovered hand movements was assessed with EEG spectral analysis and H2(15)O-PET with EMG monitoring, cortico-cortical connectivity with EEG coherence analysis (cortico-cortical coherence) and corticospinal connectivity with transcranial magnetic stimulation (TMS). As seen from comparisons with age-matched controls, our patients showed enhanced recruitment of the lateral premotor cortex of the lesioned hemisphere [Brodmann area (BA) 6], lateral premotor and to a lesser extent primary sensorimotor and parietal cortex of the contralesional hemisphere (CON-H; BA 4 and superior parietal lobule) and left cerebellum (patients versus controls, Z > 3.09). EEG coherence analysis showed that after stroke cortico-cortical connections were reduced in the stroke hemisphere but relatively increased in the CON-H (ANOVA, contrast analysis, P < 0.05), suggesting a shift of functional connectivity towards the CON-H. Nevertheless, fast conducting corticospinal transmission originated exclusively from the lesioned hemisphere. No direct ipsilateral motor evoked potentials (MEPs) could be elicited with TMS over the contralesional primary motor cortex (iM1) in stroke patients. We conclude that (i) effective recovery is based on enhanced utilization of ipsi- and contralesional resources, (ii) basic corticospinal commands arise from the lesioned hemisphere without recruitment of ('latent') uncrossed corticospinal tract fibres and (iii) increased contralesional activity probably facilitates control of recovered motor function by operating at a higher-order processing level, similar to but not identical with the extended network concerned with complex movements in healthy subjects.