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

The influence of attention and age on the occurrence of mirror movements

This study utilised a finger force task to investigate the influence of attention and age on the occurrence of motor overflow in the form of mirror movements in neurologically intact adults. Forty right-handed participants were recruited from three age groups: 20-30 years, 40-50 years, and 60-70 years. Participants were required to maintain a target force using both their index and middle fingers, representing 50% of their maximum strength capacity for that hand. Attention was directed to a hand by activating a bone conduction vibrator attached to the small finger of that hand. Based on Cabeza's (2002) model of hemispheric asymmetry reduction in older adults, it was hypothesised that mirror movements would increase with age. Furthermore, it was expected that when the attentional demands of the task were increased, motor overflow occurrence would be exacerbated for the older adult group. The results obtained provide support for the model, and qualified support for the hypothesis that increasing the attentional demands of a task results in greater motor overflow. It is proposed that the association between mirror movements and age observed in this study may result from an age-related increase in bihemispheric activation that occurs in older adults, who, unlike younger adults, benefit from bihemispheric processing for task performance.

Neural pathways mediating bilateral interactions between the upper limbs

The ease with which we perform tasks such as opening the lid of a jar, in which the two hands execute quite different actions, belies the fact that there is a strong tendency for the movements of the upper limbs to be drawn systematically towards one another. Mirror movements, involuntary contractions during intended unilateral engagement of the opposite limb, are considered pathological, as they occur in association with specific disorders of the CNS. Yet they are also observed frequently in normally developing children, and motor irradiation, an increase in the excitability of the (opposite) homologous motor pathways when unimanual movements are performed, is a robust feature of the mature motor system. The systematic nature of the interactions that occur between the upper limbs has also given rise to the expectation that functional improvements in the control of a paretic limb may occur when movements are performed in a bimanual context. In spite of the ubiquitous nature of these phenomena, there is remarkably little consensus concerning the neural basis of their mediation. In the present review, consideration is given to the putative roles of uncrossed corticofugal fibers, branched bilateral corticomotoroneuronal projections, and segmental networks. The potential for bilateral interactions to occur in various brain regions including the primary motor cortex, the supplementary motor area, non-primary motor areas, the basal ganglia, and the cerebellum is also explored. This information may provide principled bases upon which to evaluate and develop task and deficit-specific programs of movement rehabilitation and therapy.

Mirrored EMG activity during unimanual rhythmic movements

We studied instances of mirror movements--in the form of coherent EMG activity of the muscles in the arm not intended to move--during the performance of a unimanual rhythmic task in healthy adults. Epochs of involuntary muscle activity were detected and analyzed using time-resolved spectral methods. The observed frequency and phase locking between EMG patterns derived from homologous extensor muscles indicated the presence of neural cross-talk, which is relevant to the study of interlimb coordination.

Neural plasticity and bilateral movements: A rehabilitation approach for chronic stroke

Stroke interferes with voluntary control of motor actions. Although spontaneous recovery of function can occur, restoration of normal motor function in the hemiplegic upper limb is noted in fewer than 15% of individuals. However, there is increasing evidence to suggest that in addition to injury-related reorganization, motor cortex functions can be altered by individual motor experiences. Such neural plasticity has major implications for the type of rehabilitative training administered post-stroke. This review proposes that noteworthy upper extremity gains toward motor recovery evolve from activity-dependent intervention based on theoretical motor control constructs and interlimb coordination principles. Founded on behavioral and neurophysiological mechanisms, bilateral movement training/practice has shown great promise in expediting progress toward chronic stroke recovery in the upper extremity. Planning and executing bilateral movements post-stroke may facilitate cortical neural plasticity by three mechanisms: (a) motor cortex disinhibition that allows increased use of the spared pathways of the damaged hemisphere, (b) increased recruitment of the ipsilateral pathways from the contralesional or contralateral hemisphere to supplement the damaged crossed corticospinal pathways, and (c) upregulation of descending premotorneuron commands onto propriospinal neurons.

Interhemispheric Coupling of Corticospinal Excitability Is Suppressed During Voluntary Muscle Activation

Motor-evoked potentials (MEPs) after transcranial magnetic stimulation (TMS) show a trial-to-trial variation in size at rest that is positively correlated for muscles of the same, and opposite, upper limbs. To investigate the mechanisms responsible for this we have examined the effect of voluntary activation on the correlated fluctuations of MEP size. In 8 subjects TMS was concurrently applied to the motor cortex of each hemisphere using 2 figure-8 coils. MEPs ( n = 50) were recorded from left and right first dorsal interosseous (FDI), abductor digiti minimi (ADM), and extensor digitorum communis. At rest, MEPs were significantly positively correlated for pairs of muscles of the same (75% of comparisons) and opposite limb (56% of comparisons). The correlation for within-limb muscle pairs was strongest for FDI and ADM. In contrast, between-limb MEP correlations showed no somatotopic organization. Voluntary activation reduced the strength of MEP correlations between limbs, even for muscle pairs that remained at rest while a remote upper limb muscle was active. In contrast, activation of a remote muscle did not affect the strength of MEP correlation for muscle pairs within the same limb that remained at rest. For within-limb comparisons, activation of one or both muscles of a pair reduced the strength of the MEP correlation, but to a lesser extent than for between-limb pairs. It is concluded that the process linking corticospinal excitability in the two hemispheres is suppressed during voluntary activation, and that different processes contribute to common fluctuations in MEP size for muscles within the same limb.

Ipsilateral Motor Cortex Activity During Unimanual Hand Movements Relates to Task Complexity

Functional imaging studies have revealed recruitment of ipsilateral motor areas during the production of sequential unimanual finger movements. This phenomenon is more prominent in the left hemisphere during left-hand movements than in the right hemisphere during right-hand movements. Here we investigate whether this lateralization pattern is related specifically to the sequential structure of the unimanual action or generalizes to other complex movements. Using event-related fMRI, we measured activation changes in the motor cortex during three types of unimanual movements: repetitions of a sequence of movements with multiple fingers, repetitive “chords” composed of three simultaneous key presses, and simple repetitive tapping movements with a single finger. During sequence and chord movements, strong ipsilateral activation was observed and was especially pronounced in the left hemisphere during left-hand movements. This pattern was evident for both right-handed and, to a lesser degree, left-handed individuals. Ipsilateral activation was less pronounced in the tapping condition. The site of ipsilateral activation was shifted laterally, ventrally, and anteriorly with respect to that observed during contralateral movements and the time course of activation implied a role in the execution rather than planning of the movement. A control experiment revealed that strong ipsilateral activity in left motor cortex is specific to complex movements and does not depend on the number of required muscles. These findings indicate a prominent role of left hemisphere in the execution of complex movements independent of the sequential nature of the task.

Reaching beyond the midline: why are human brains cross wired?

The crossing of nerve tracts from one hemisphere in the brain to the contralateral sense organ or limb is a common pattern throughout the CNS, which occurs at specialised bridging points called decussations or commissures. Evolutionary and teleological arguments suggest that midline crossing emerged in response to distinct physiological and anatomical constraints. Several genetic and developmental disorders involve crossing defects or mirror movements, including Kallmann's and Klippel-Feil syndrome, and further defects can also result from injury. Crossed pathways are also involved in recovery after CNS lesions and may allow for compensation for damaged areas. The development of decussation is under the control of a host of signalling molecules. Growing understanding of the molecular processes underlying the formation of these structures offers hope for new diagnostic and therapeutic interventions.

Stabilization of bimanual coordination due to active interhemispheric inhibition: a dynamical account

Based on recent brain-imaging data and congruent theoretical insights, a dynamical model is derived to account for the patterns of brain activity observed during stable performance of bimanual multifrequency patterns, as well as during behavioral instabilities in the form of phase transitions between such patterns. The model incorporates four dynamical processes, defined over both motor and premotor cortices, which are coupled through inhibitory and excitatory inter- and intrahemispheric connections. In particular, the model underscores the crucial role of interhemispheric inhibition in reducing the interference between disparate frequencies during stable performance, as well as the failure of this reduction during behavioral transitions. As an aside, the model also accounts for in- and antiphase preferences during isofrequency movements. The viability of the proposed model is illustrated by magnetoencephalographic signals that were recorded from an experienced subject performing a polyrhythmic tapping task that was designed to induce transitions between multifrequency patterns. Consistent with the models dynamics, contra- and ipsilateral cortical areas of activation were frequency- and phase-locked, while their activation strength changed markedly in the vicinity of transitions in coordination.

A transcranial magnetic stimulation study of the ipsilateral silent period in lower limb muscles

The lower limb ipsilateral silent periods (ISP) were determined with transcranial magnetic stimulation in 30 normal subjects using a round coil. The mean duration and transcallosal conduction time were comparable to values obtained from upper limb recordings. No age-related correlation was found for either parameter, corroborating previous imaging and pathological studies of interhemispheric pathways. Our results highlight the feasibilty of eliciting ISPs in the lower limbs, relevant for future studies of interhemispheric interaction in clinical and research settings.

Effect of Transcranial Magnetic Stimulation on Bimanual Movements

Transcranial magnetic stimulation (TMS) of the motor cortex can interrupt voluntary contralateral rhythmic limb movements. Using the method of “resetting index” (RI), our study investigated the TMS effect on different types of bimanual movements. Six normal subjects participated. For unimanual movement, each subject tapped either the right or left index finger at a comfortable rate. For bimanual movement, index fingers of both hands tapped in the same (in-phase) direction or in the opposite (antiphase) direction. TMS was applied to each hemisphere separately at various intensities from 0.5 to 1.5 times motor threshold (MT). TMS interruption of rhythm was quantified by RI. For the unimanual movements, TMS disrupted both contralateral and ipsilateral rhythmic hand movements, although the effect was much less in the ipsilateral hand. For the bimanual in-phase task, TMS could simultaneously reset the rhythmic movements of both hands, but the effect on the contralateral hand was less and the effect on the ipsilateral hand was more compared with the unimanual tasks. Similar effects were seen from right and left hemisphere stimulation. TMS had little effect on the bimanual antiphase task. The equal effect of right and left hemisphere stimulation indicates that neither motor cortex is dominant for simple bimanual in-phase movement. The smaller influence of contralateral stimulation and the greater effect of ipsilateral stimulation during bimanual in-phase movement compared with unimanual movement suggest hemispheric coupling. The antiphase movements were resistant to TMS disruption, and this suggests that control of rhythm differs in the 2 tasks. TMS produced a transient asynchrony of movements on the 2 sides, indicating that both motor cortices might be downstream of the clocking command or that the clocking is a consequence of the 2 hemispheres communicating equally with each other.

Investigating the cortical origins of motor overflow

Motor overflow refers to the involuntary movements which may accompany the production of voluntary movements. While overflow is not usually seen in the normal population, it does present in children and the elderly, as well as those suffering certain neurological dysfunctions. Advancements in methodology over the last decade have allowed for more convincing conclusions regarding the cortical origins of motor overflow. However, despite significant research, the exact mechanism underlying the production of motor overflow is still unclear. This review presents a more comprehensive conceptualization of the theories of motor overflow, which have often been only vaguely defined. Further, the major findings are explored in an attempt to differentiate the competing theories of motor overflow production. This exploration is done in the context of a range of neurological and psychiatric disorders, in order to elucidate the possible underlying mechanisms of overflow.

Patterns of abnormal motor cortex excitability in atypical parkinsonian syndromes

OBJECTIVE

Multiple system atrophy (MSA), progressive supranuclear palsy (PSP), and corticobasal-ganglionic degeneration (CBGD) are all clinically characterized by an akinetic-rigid syndrome together with a variety of additional signs. We hypothesised that these atypical parkinsonian syndromes (APS) will show distinctive patterns in their motor output upon transcranial magnetic stimulation (TMS) due to their different underlying anatomico-functional deficits.

METHODS

We performed single and paired-pulse TMS and assessed inhibitory and excitatory response parameters from the first dorsal interosseus muscles in 13 patients with MSA, 18 with PSP, 13 with CBGD, 15 patients with Parkinson's disease and 17 healthy subjects.

RESULTS

PSP and MSA patients had significantly enlarged response amplitudes at rest, reduced intracortical inhibition (ICI) and prolonged ipsi- and contralateral silent periods, whereas CBGD patients showed significantly increased motor thresholds, smaller response amplitudes at rest, shortened contralateral silent period, reduced transcallosal inhibition and a reduced ICI. In 22% of APS patients ipsilateral motor responses occurred in upper limb muscles irrespective of the underlying disease.

CONCLUSIONS

Our results indicate that motor cortex disinhibition is predominant in patients with PSP and MSA. In CBGD more severe neuronal cell loss in the motor cortex itself may lead to hypoexcitability of corticospinal and transcallosal pathways.

Exaggerated redundancy gain in the split brain: A hemispheric coactivation account

Recent studies of redundancy gain indicate that it is especially large when redundant stimuli are presented to different hemispheres of an individual without a functioning corpus callosum. This suggests the hypothesis that responses to redundant stimuli are speeded partly because both hemispheres are involved in the activation of the response. A simple formal model incorporating this idea is developed and then elaborated to account for additional related findings. Predictions of the latter model are in good qualitative agreement with data from a number of sources, and there is neuroanatomic and psychophysiological support for its underlying structure.

Bilateral responses of upper limb muscles to transcranial magnetic stimulation in human subjects

Anatomical and behavioural work on primates has shown bilateral innervation of axial and proximal limb muscles, and contralateral control of distal limb muscles. The following study examined if a clear boundary exists between the distal and proximal upper limb muscles that are controlled contralaterally or bilaterally. The right motor cortical area representing the upper limb was stimulated, while surface EMG was recorded bilaterally from various upper limb muscles during rest and phasic voluntary contractions. Peak-to-peak amplitude of motor evoked potential (MEP) was measured for each muscle on both sides. The ratio R = (ipsilateral MEP: contralateral MEP) was calculated for seven pairs of muscles. For each of the seven pairs, R was less than 1.0, implying that for each muscle and subject, the contralateral control is stronger. The boundary where R changed from almost zero to a clearly measurable magnitude depended on the subject. Ipsilateral MEPs from trapezius and pectoralis could be recorded with a small background contraction from almost all subjects; on the other hand, in deltoid and biceps brachii, ipsilateral MEPs were observed only with bimanual phasic contractions. The forearm and hand muscles, in general, did not show any ipsilateral MEPs. Major differences between subjects lay in the presence or the absence of ipsilateral MEPs in biceps brachii and deltoid, without defining a sharp boundary between proximal and distal muscles.

Motor sequence complexity and performing hand produce differential patterns of hemispheric lateralization

Studies in brain damaged patients conclude that the left hemisphere is dominant for controlling heterogeneous sequences performed by either hand, presumably due to the cognitive resources involved in planning complex sequential movements. To determine if this lateralized effect is due to asymmetries in primary sensorimotor or association cortex, whole-brain functional magnetic resonance imaging was used to measure differences in volume of activation while healthy right-handed subjects performed repetitive (simple) or heterogeneous (complex) finger sequences using the right or left hand. Advanced planning, as evidenced by reaction time to the first key press, was greater for the complex than simple sequences and for the left than right hand. In addition to the expected greater contralateral activation in the sensorimotor cortex (SMC), greater left hemisphere activation was observed for left, relative to right, hand movements in the ipsilateral left superior parietal area and for complex, relative to simple, sequences in the left premotor and parietal cortex, left thalamus, and bilateral cerebellum. No such volumetric asymmetries were observed in the SMC. Whereas the overall MR signal intensity was greater in the left than right SMC, the extent of this asymmetry did not vary with hand or complexity level. In contrast, signal intensity in the parietal and premotor cortex was greater in the left than right hemisphere and for the complex than simple sequences. Signal intensity in the caudal anterior cerebellum was greater bilaterally for the complex than simple sequences. These findings suggest that activity in the SMC is associated with execution requirements shared by the simple and complex sequences independent of their differential cognitive requirements. In contrast, consistent with data in brain damaged patients, the left dorsal premotor and parietal areas are engaged when advanced planning is required to perform complex motor sequences that require selection of different effectors and abstract organization of the sequence, regardless of the performing hand.

Towards improved clinical and physiological assessments of recovery in spinal cord injury: a clinical initiative

Clinical practice and scientific research may soon lead to treatments designed to repair spinal cord injury. Repair is likely to be partial in the first trials, extending only one or two segments below the original injury. Furthermore, treatments that are becoming available are likely to be applied to the thoracic spinal cord to minimise loss of function resulting from damage to surviving connections. These provisos have prompted research into the improvement of clinical and physiological tests designed (1) to determine the level and density of a spinal cord injury, (2) to provide reliable monitoring of recovery over one or two spinal cord segments, and (3) to provide indices of function provided by thoracic spinal root innervation, presently largely ignored in assessment of spinal cord injury. This article reviews progress of the Clinical Initiative, sponsored by the International Spinal Research Trust, to advance the clinical and physiological tests of sensory, motor and autonomic function needed to achieve these aims.

Motor representation in patients rapidly recovering after stroke: a functional magnetic resonance imaging and transcranial magnetic stimulation study

OBJECTIVE

Neuroimaging studies have suggested an evolution of the brain activation pattern in the course of motor recovery after stroke. Initially poor motor performance is correlated with an recruitment of the uninjured hemisphere that continuously vanished until a nearly normal (contralateral) activation pattern is achieved and motor performance is good. Here we were interested in the early brain activation pattern in patients who showed a good and rapid recovery after stroke.

METHODS

Ten patients with first-ever ischemic stroke affecting motor areas had to perform self-paced simple or more complex movements with the affected or the unaffected hand during functional magnetic resonance imaging (fMRI). The location and number of activated voxels above threshold were determined. To study possible changes in the cortical motor output map the amplitude of the motor evoked potentials (MEP) and the extent of the excitable area were determined using transcranial magnetic stimulation (TMS).

RESULTS

The pattern of activation observed with movements of the affected and the unaffected hand was similar. In the simple motor task significant (P<0.05) increases were found in the primary motor cortex ipsilateral to the movement, the supplementary motor area and the cerebellar hemisphere contralateral to the movement during performance with the affected hand compared to movements with the unaffected hand. When comparing simple with more complex movements performed with either the affected or the unaffected hand, a further tendency to increased activation in motor areas was observed. The amplitude of MEPs obtained from the affected hemisphere was smaller and the extent of cortical output maps was decreased compared to the unaffected hemisphere; but none of the patients showed MEPs at the affected hand when the ipsilateral unaffected motor cortex was stimulated.

CONCLUSIONS

Despite a rapid and nearly complete motor recovery the brain activation pattern was associated with increased activity in (bilateral) motor areas as revealed with fMRI. TMS revealed impaired motor output properties, but failed to demonstrate ipsilateral motor pathways. Successful recovery in our patients may therefore rely on the increased bilateral activation of existing motor networks spared by the injury.

Transcranial magnetic stimulation in children

Single and paired pulse transcranial magnetic stimulation (TMS) provide a non-invasive, painless method of probing the motor system. These techniques are of particular interest for studying maturation of the motor system and may provide insights into those developmental disabilities strongly associated with specific delays of motor development. This article will review studies using single pulse and paired pulse TMS in children, with particular reference to insights into neurodevelopment in children. It will also briefly touch on the potential of TMS as a diagnostic tool in neurological disorders. It will not address the use of repetitive TMS in children.

Separate ipsilateral and contralateral corticospinal projections in congenital mirror movements: Neurophysiological evidence and significance for motor rehabilitation

The neurophysiological hallmark of congenital mirror movements (MM) are fast-conducting corticospinal projections from the hand area of one primary motor cortex to both sides of the spinal cord. It is still unclear whether the abnormal ipsilateral projection originates through branching fibres from the normal contralateral projection or constitutes a separate ipsilateral projection. To clarify this question, we used focal paired-pulse transcranial magnetic stimulation to test task-related modulation of short-interval intracortical inhibition (SICI) in the abductor pollicis brevis (APB) muscles of a 15-year-old girl (Patient 1) and a 40-year-old woman (Patient 2) with congenital MM. In both patients, during intended unilateral APB contraction, SICI decreased markedly in the "task" APB but remained unchanged in the "mirror" APB when compared to muscle rest. In contrast, spinal excitability as tested with H reflexes increased similarly in the task and mirror flexor carpi radialis muscles. This dissociation of task-related SICI modulation strongly supports the existence of a separate ipsilateral fast-conducting corticospinal projection. In Patient 1, we tested the functional significance of this separate ipsilateral projection during 7 months of motor rehabilitation training, which was designed to facilitate unilateral finger movements. A marked reduction of MM was observed after training, suggesting that unwanted mirror activity in the ipsilateral pathway can be suppressed by learning.

Electrical stimulation driving functional improvements and cortical changes in subjects with stroke

It has been proposed that somatosensory stimulation in the form of electromyographically triggered neuromuscular electrical stimulation (NMES) to the peripheral nerve can influence functional measures of motor performance in subjects with stroke and can additionally produce changes in cortical excitability. Using a controlled, double-blind design, we studied the effects of intensive (60 h/3 weeks) treatment at home with NMES compared with a sham treatment, applied to the extensor muscles of the hemiplegic forearm to facilitate hand opening in 16 chronic stroke subjects. We investigated improvement in functional use of the hand and change in cortical activation as measured by functional magnetic resonance imaging (fMRI). Following treatment, subjects improved on measures of grasp and release of objects (Box and Block Test and Jebsen Taylor Hand Function Test [JTHFT]: small objects, stacking, heavy cans), isometric finger extension strength, and self-rated Motor Activity Log (MAL): Amount of Use and How Well score. The sham subjects did not improve on any grasp and release measure or self-rated scale, but did improve on isometric finger extension strength. Importantly, however, following crossover, these subjects improved further in the measure of strength, grasp and release (Box and Block [JTHFT]: page turning), and self-rated MAL: Amount of Use score and How Well score. Using fMRI and a finger-tracking task, an index of cortical intensity in the ipsilateral somatosensory cortex increased significantly from pre-test to post-test following treatment. Cortical activation, as measured by voxel count, did not change. These findings suggest that NMES may have an important role in stimulating cortical sensory areas allowing for improved motor function.

Long-latency motor evoked potentials in congenital hemiplegia

OBJECTIVE

To investigate long-latency motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation in congenital hemiplegia (CH) and to seek for correlation with paretic hand movement deficits.

METHODS

MEPs were recorded from the first dorsal interosseous of both hands in 12 CH patients and 12 age-matched controls; dexterity and upper limb function were quantitatively assessed in both groups.

RESULTS

In CH patients, long-latency MEPs, occurring much later than the commonly reported MEPs, were frequently observed in the paretic and non-paretic hands. Four distinct groups of long-latency MEPs were found, each cluster being identified by its mean latency, namely 35, 85, 160 and 225 ms. The residual dexterity of the paretic hand was correlated with the presence of contralateral MEPs with a 20 and 225 ms latency and was negatively correlated with ipsilateral MEPs, irrespective of their latency. In controls, only few MEPs with a latency of 225 ms were found in 4 out of 12 subjects.

CONCLUSIONS

The pattern of MEPs found in CH patients differs dramatically from that reported in adult stroke patients, suggesting that long-latency MEPs are a rather distinctive consequence of early corticospinal lesions. The hypothesis that a given cluster of long-latency MEPs is mediated by a particular pathway appears very unlikely. Rather, we suggest that an exacerbation of cortical and/or spinal excitability is at the origin of these long-latency MEPs.

Instabilities during antiphase bimanual movements: are ipsilateral pathways involved?

The spatial and temporal coupling between the hands is known to be very robust during movements which use homologous muscles (in-phase or symmetric movements). In contrast, movements using nonhomologous muscles (antiphase or asymmetric movements) are less stable and exhibit a tendency to undergo a phase transition to in-phase movements as movement frequency increases. The instability during antiphase movements has been modeled in terms of signal interference mediated by the ipsilateral corticospinal pathways. In this study we report that participants in whom distal ipsilateral motor-evoked potentials could be elicited with transcranial magnetic stimulation (TMS), exhibited higher variability during a bimanual circling task than participants whose ipsilateral pathways could not be transcranially activated. These results suggest that ipsilateral control of the limb affects the level of bimanual coupling, and may contribute to uncoupling phenomena observed during asymmetric coordination.

Control of hand movements after striatocapsular stroke: high-resolution temporal analysis of the function of ipsilateral activation

OBJECTIVE

Hemiparesis due to infarction of the middle cerebral artery has become an increasingly important focus of research on cortical plasticity. Positron emission tomography and functional magnetic resonance imaging studies in such patients found involvement of the hemisphere ipsilateral to the affected hand related to movements of this hand. To understand the function of this ipsilateral activation, the present study investigated movement-related electroencephalogram (EEG) potentials in patients and healthy control subjects to measure timing of ipsi- and contralateral activation relative to movement onset.

METHODS

Thirteen patients were investigated in their chronic stage. Their pyramidal tracts were affected by infarctions of the middle cerebral artery at striatocapsular level. EEG potentials were recorded from 26 scalp electrodes while patients were pressing a key with their right or left index finger within a warned choice-response task.

RESULTS

Beginning 200 ms before responses of the affected hand, there was normal contralateral preponderance of EEG negativity. Briefly after response onset, however, the other unaffected hemisphere, ipsilateral to the responding hand, became additionally active. This pattern did not occur with responses made by the unaffected hand nor in healthy participants.

CONCLUSIONS

The timing of the onset of ipsilateral activity precludes its role in response initiation. Rather, this activity may indicate reflex-like activation of the unaffected motor system to compensate for possible failure of the affected hand.

The ipsilateral human motor cortex can functionally compensate for acute contralateral motor cortex dysfunction

What promotes motor recovery from stroke? To date, studies of recovery from stroke have shown alterations in function in various cortical areas, including the contralesional (unaffected) motor cortex (M1). However, whether these changes contribute to recovery or are mere epiphenomena remains unclear. We therefore sought evidence that the ipsilateral M1 can compensate for dysfunction of the contralateral M1. We recorded the change in force production during a finger-tapping task in response to acute disruption of M1 function by repetitive transcranial magnetic stimulation (rTMS). Neither control (occipital) nor ipsilateral M1 rTMS lead to a change in tapping force. RTMS over contralateral M1 had a short-lived effect and induced changes in ipsilateral M1 excitability around the time that these behavioral effects abated, consistent with delayed compensation by the ipsilateral M1. Simultaneous bilateral M1 stimulation, designed to prevent compensation by the ipsilateral M1, had a large and prolonged effect on tapping force. This is the first demonstration that the ipsilateral primary motor cortex is capable of functionally significant compensation for focal contralateral cortical dysfunction in the adult human and provides a rational basis for interventional treatments aimed at promoting functional compensation in unaffected cortical areas after stroke.

Visuo-motor control of the ipsilateral hand: evidence from right brain-damaged patients

We investigated the extent to which the right hemisphere is involved in the control of the ipsilateral hand by analysing the kinematics of right-hand prehension in right brain-damaged (RBD) patients. We required patients to grasp one of five possible objects, equally-sized and distributed over a 40 degrees wide workspace. With the purpose of investigating the right hemisphere contribution to the on-line visuo-motor control, we also assessed patients' ability to correct their movement "in-flight", in response to a sudden change of object position. Patients' performance was compared to that of aged-matched controls. A Younger group of healthy subjects, matching the population classically tested on double-step paradigms, was also evaluated to fully assess whether patients' kinematics could be partially due to normal ageing. As a further aim, the possible influence of hemispatial neglect was evaluated by comparing the performances of right brain-damaged patients with and without neglect. In normal subjects, the results confirmed and extended the notion of (a). positional tuning of grip formation, and (b). fast reactions following a change in object position. In addition, subtle effects of ageing on visuo-motor behaviour were shown by less efficient movement correction in the Elderly group. Patients executing reach-to-grasp actions into the left contralesional hemispace were selectively affected in both temporal and spatial aspects of movements. While their performances were relatively well preserved in the right hemispace, patients did not show positional tuning of grip formation, nor fast corrections of their movements when acting in the left hemispace. Interestingly, similar deficits were found irrespective of the presence of neglect. These results show that the right hemisphere contributes to the processing of visuo-motor information that is necessary for executing actions with the ipsilateral hand in the contralateral space.

Organization of ipsilateral excitatory and inhibitory pathways in the human motor cortex

Motor cortex stimulation has both excitatory and inhibitory effects on ipsilateral muscles. Excitatory effects can be assessed by ipsilateral motor-evoked potentials (iMEPs). Inhibitory effects include an interruption of ipsilateral voluntary muscle activity known as the silent period (iSP) and a reduction in corticospinal excitability evoked by conditioning stimulation of the contralateral motor cortex (interhemispheric inhibition, IHI). Both iSP and IHI may be mediated by transcallosal pathways. Their relationship to the contralateral corticospinal projection and whether iSP and IHI represent the same phenomenon remain unclear. The neuronal population activated by transcranial magnetic stimulation (TMS) is highly dependent on the direction of the induced current in the brain. We examined the relationship among iMEP, iSP, IHI, and the contralateral corticospinal system by examining the effects of different stimulus intensities and current directions. Surface electromyography (EMG) was recorded from both first dorsal interosseous (FDI) muscles. The iSP in the right FDI muscle was obtained by right motor cortex stimulation during voluntary muscle contraction. IHI was examined by conditioning stimulation of the right motor cortex followed by test stimulation of the left motor cortex at interstimulus intervals (ISIs) of 2-80 ms. The induced current directions tested in the right motor cortex were anterior medial (AM), posterior medial (PM), posterior lateral, and anterior lateral (AL). Contralateral MEPs (cMEPs) had the lowest threshold with the AM direction and the shortest latency with the PM direction. iMEPs were present in 8 of 10 subjects. Both iMEP and IHI did not show significant directional preference. iSP was observed in all subjects with the highest threshold for the AL direction and the longest duration for the AM direction. cMEP, iSP, and IHI all increased with stimulus intensity up to approximately 75% stimulator output. Target muscle activation decreased IHI at 8-ms ISI but had little effect on IHI at 40-ms ISI. iSP and IHI at 8-ms ISI did not correlate at any stimulus intensities and current directions tested, and factor analysis showed that they are explained by different factors. However, active IHI at 40-ms ISI was explained by the same factor as iSP. The different directional preference for cMEP compared with iMEP and IHI suggests that these ipsilateral effects are mediated by populations of cortical neurons that are different from those activating the corticospinal neurons. iSP and IHI do not represent the same phenomenon and should be considered complementary measures of ipsilateral inhibition.

Motor recovery and cortical reorganization after constraint-induced movement therapy in stroke patients: a preliminary study

Constraint-induced movement therapy (CIMT) is a physical rehabilitation regime that has been previously shown to improve motor function in chronic hemiparetic stroke patients. However, the neural mechanisms supporting rehabilitation-induced motor recovery are poorly understood. The goal of this study was to assess motor cortical reorganization after CIMT using functional magnetic resonance imaging (fMRI). In a repeated-measures design, 4 incompletely recovered chronic stroke patients treated with CIMT underwent motor function testing and fMRI. Five age-matched normal subjects were also imaged. A laterality index (LI) was determined from the fMRI data, reflecting the distribution of activation in motor cortices contralateral compared with ipsilateral to the moving hand. Pre-intervention fMRI showed a lower LI during affected hand movement of stroke patients (LI = 0.23+/-0.07) compared to controls (LI unaffected patient hand = 0.65+/-0.10; LI dominant normal hand = 0.65+/-0.11; LI nondominant normal hand = 0.69+/-0.11; P < 0.05) due to trends toward increased ipsilateral motor cortical activation. Motor function testing showed that patients made significant gains in functional use of the stroke-affected upper extremity (detected by the Motor Activity Log) and significant reductions in motor impairment (detected by the Fugl-Meyer Stroke Scale and the Wolf Motor Function Test) immediately after CIMT, and these effects persisted at 6-month follow-up. The behavioral effects of CIMT were associated with a trend toward a reduced LI from pre-intervention to immediately post-intervention (LI = -0.01+/-0.06, P = 0.077) and 6 months post-intervention (LI = -0.03+/-0.15). Stroke-affected hand movement was not accompanied by mirror movements during fMRI, and electromyographic measures of mirror recruitment under simulated fMRI conditions were not correlated with LI values. These data provide preliminary evidence that gains in motor function produced by CIMT in chronic stroke patients may be associated with a shift in laterality of motor cortical activation toward the undamaged hemisphere.

Somatotopy in the ipsilateral primary motor cortex

Conflicting reports exist about the occurrence, reliability and localization of activation in the ipsilateral primary motor cortex (M1). We re-examined this issue with functional magnetic resonance imaging in 12 volunteers performing right hand, finger, wrist, elbow, foot and tongue movements in two separate sessions. Ipsilateral M1 activation was inconsistently and non-reliably present during all movements: in 54% of all hand, 50% elbow, 46% finger, 33% wrist, and in 17% of all foot experiments. When compared to contralateral M1, the volumes and maximum t-values were always smaller. The ipsilateral M1 body representation was somatotopically organized with coordinates similar to the contralateral M1. Finally, the presence of ipsilateral M1 activation depended on the global activation level in other motor-related areas, which was significantly increased, when ipsilateral M1 activation was detected.

Motor cortex activation is preserved in patients with chronic hemiplegic stroke

Many central nervous system conditions that cause weakness, including many strokes, injure corticospinal tract but leave motor cortex intact. Little is known about the functional properties of surviving cortical regions in this setting, in part because many studies have used probes reliant on the corticospinal tract. We hypothesized that many features of motor cortex function would be preserved when assessed independent of the stroke-affected corticospinal tract. Functional MRI was used to study 11 patients with chronic hemiplegia after unilateral stroke that spared regions of motor cortex. Activation in stroke-affected hemisphere was evaluated using 3 probes independent of affected corticospinal tract: passive finger movement, a hand-related visuomotor stimulus, and tapping by the nonstroke index finger. The site and magnitude of cortical activation were similar when comparing the stroke hemisphere to findings in 19 control subjects. Patients activated each of 8 cortical regions with similar frequency as compared to controls, generally with a smaller activation volume. In some cases, clinical measures correlated with the size or the site of stroke hemisphere activation. The results suggest that, despite stroke producing contralateral hemiplegia, surviving regions of motor cortex actively participate in the same proprioceptive, visuomotor, and bilateral movement control processes seen in control subjects.

Repetitive task practice: a critical review of constraint-induced movement therapy in stroke

BACKGROUND

Constraint-induced (CI) movement therapy (also called forced use by some investigators and clinicians) has gained increasing popularity as a treatment mode for restoring function in the upper extremities of patients with stroke. The purpose of this article is to review the concept of constraint-induced movement therapy and provide a critical analysis of the existing data.

REVIEW SUMMARY

The evidence to date offers encouragement for the application of this procedure for patients who have some movement recovery out of synergy. Success may be contingent on patient cooperation and intense repetitive use with applications of retraining through practice and shaping. The extent to which each of the latter elements influences the magnitude of recovery is still unclear. However, task novelty and challenge seem important to recovery of function. There are several methods used to map cortical changes after stroke. At this time, transcranial magnetic stimulation is the primary vehicle used to assess motor cortical reorganization after CI therapy in humans.

CONCLUSIONS

Accumulating data indicate that the size of a cortical area representative of a muscle does expand and its center of gravity does change with CI therapy.

Hand motor recovery after stroke: a transcranial magnetic stimulation mapping study of motor output areas and their relation to functional status

The respective contributions of the stroke and undamaged hemispheres to motor recovery after stroke remains controversial. The aim of this article is to evaluate the relationship between location and size of cortical motor areas and outcome after stroke. Twelve controls and 12 stroke patients were studied. Hand cortical motor output areas were determined using transcranial magnetic stimulation. Motor-evoked potentials were recorded simultaneouslyfrom both hands. Functional motor abilities were evaluated using well-validated measures. Surface area, weighted surface area, and center of gravity of motor output areas were calculated. Different patterns of motor output areas to the paretic band were observed; there was no motor output from the stroke hemisphere in patients with poor outcome, contrasting to large motor output area in the stroke hemisphere in patients with good outcome, regardless of infarct size or location. A significant correlation was found between measures of motor outcome in the stroke-affected upper extremity and both the surface area and weight of the central motor output area in the stroke hemisphere. No ipsilateral motor response was obtained after stimulation of either hemisphere. These data support an association between preservation of cortical motor output area to the paretic hand in the stroke hemisphere and good motor outcome.

Pseudo-bilateral hand motor responses evoked by transcranial magnetic stimulation in patients with deep brain stimulators

OBJECTIVES

In 3 of 5 patients with dystonia and bilaterally implanted deep brain stimulating electrodes, focal transcranial magnetic stimulation (TMS) of one motor cortex elicited bilateral hand motor responses. The aim of this study was to clarify the origin of these ipsilateral responses.

METHODS

TMS and electrical stimulation of corticospinal fibres by the implanted electrodes were performed and the evoked hand motor potentials were analysed.

RESULTS

In comparison with responses elicited by contralateral motor cortex stimulation, ipsilateral responses were smaller in amplitude (3.0+/-1.4 versus 5.8+/-1.5 mV), had shorter peak latencies (first negative peak: 20.9+/-0.8 versus 25.1+/-0.4 ms) and were followed by a shorter-lasting silent period (46+/-4 versus 195+/-35 ms). Ipsilateral responses following TMS had similar peak latencies to responses elicited subcortically by deep brain stimulation (DBS) (20.4+/-0.9 ms).

CONCLUSIONS

Hand motor responses ipsilateral to TMS result from a subcortical activation of corticospinal fibres, via the implanted electrode in the other hemisphere, secondary to currents induced by TMS in subcutaneous wire loops that underlie the magnetic coil. Studies of TMS in patients with DBS have to take this potential source of confounding into account.

Simulating transcranial magnetic stimulation during PET with a large-scale neural network model of the prefrontal cortex and the visual system

Transcranial magnetic stimulation (TMS) exerts both excitatory and inhibitory effects on the stimulated neural tissue, although little is known about the neurobiological mechanisms by which it influences neuronal function. TMS has been used in conjunction with PET to examine interregional connectivity of human cerebral cortex. To help understand how TMS affects neuronal function, and how these effects are manifested during functional brain imaging, we simulated the effects of TMS on a large-scale neurobiologically realistic computational model consisting of multiple, interconnected regions that performs a visual delayed-match-to-sample task. The simulated electrical activities in each region of the model are similar to those found in single-cell monkey data, and the simulated integrated summed synaptic activities match regional cerebral blood flow (rCBF) data obtained in human PET studies. In the present simulations, the excitatory and inhibitory effects of TMS on both locally stimulated and distal sites were studied using simulated behavioral measures and simulated PET rCBF results. The application of TMS to either excitatory or inhibitory units of the model, or both, resulted in an increased number of errors in the task performed by the model. In experimental studies, both increases and decreases in rCBF following TMS have been observed. In the model, increasing TMS intensity caused an increase in rCBF when TMS exerted a predominantly excitatory effect, whereas decreased rCBF following TMS occurred if TMS exerted a predominantly inhibitory effect. We also found that regions both directly and indirectly connected to the stimulating site were affected by TMS.

Spinal and supraspinal factors in human muscle fatigue

Muscle fatigue is an exercise-induced reduction in maximal voluntary muscle force. It may arise not only because of peripheral changes at the level of the muscle, but also because the central nervous system fails to drive the motoneurons adequately. Evidence for "central" fatigue and the neural mechanisms underlying it are reviewed, together with its terminology and the methods used to reveal it. Much data suggest that voluntary activation of human motoneurons and muscle fibers is suboptimal and thus maximal voluntary force is commonly less than true maximal force. Hence, maximal voluntary strength can often be below true maximal muscle force. The technique of twitch interpolation has helped to reveal the changes in drive to motoneurons during fatigue. Voluntary activation usually diminishes during maximal voluntary isometric tasks, that is central fatigue develops, and motor unit firing rates decline. Transcranial magnetic stimulation over the motor cortex during fatiguing exercise has revealed focal changes in cortical excitability and inhibitability based on electromyographic (EMG) recordings, and a decline in supraspinal "drive" based on force recordings. Some of the changes in motor cortical behavior can be dissociated from the development of this "supraspinal" fatigue. Central changes also occur at a spinal level due to the altered input from muscle spindle, tendon organ, and group III and IV muscle afferents innervating the fatiguing muscle. Some intrinsic adaptive properties of the motoneurons help to minimize fatigue. A number of other central changes occur during fatigue and affect, for example, proprioception, tremor, and postural control. Human muscle fatigue does not simply reside in the muscle.

Patients with capsular infarct and Wallerian degeneration show persistent regional premotor cortex activation on functional magnetic resonance imaging

BACKGROUND AND PURPOSE

By using neurorehabilitation outcome measures and functional magnetic resonance imaging (fMRI), we attempted to elucidate the effect of Wallerian degeneration (WD) in the pyramidal tract distal to a posterior capsular stroke on functional recovery.

METHODS

In 18 patients with pure motor hemiparesis caused by capsular infarct, we identified the presence of WD and then tested whether it affected the rate of motor improvement and the final motor outcome. The discharge T2-weighted MRI (139 +/- 5 days on average after stroke) showed WD in 10 of 18 patients (WD-positive, n = 10; WD-negative, n = 8). All patients performed mass grasping of paretic fingers before and after inpatient neurorehabilitation for the fMRI.

RESULTS

Demographic characteristics, rate of disability change, final motor status, and volume of lesion were comparable between the groups. On the first fMRI, patterns of fMRI activation in the sensorimotor cortex, premotor cortex (PMC), and supplementary motor area were comparable. However, on the second fMRI, considerably more patients in the WD-positive group (8 out of 10) exhibited persistent contralateral activation in PMC than in the WD-negative group (1 out of 8; P = .0044, chi-square test). Ipsilateral PMC was also more frequently activated (P = .04) in WD-positive patients than in WD-negative patients.

CONCLUSIONS

Persistent WD had no effect on the impairment or disability outcome; however, it was associated with novel regional activation on repeat fMRI after recovery. To determine whether persistent PMC activation resulted from effort or represents a general effect of WD on motor recovery will require a longer follow-up time and more precise control of functional measurement during imaging.

Ipsilateral motor responses to focal transcranial magnetic stimulation in healthy subjects and acute-stroke patients

BACKGROUND AND PURPOSE

Prevalence and characteristics of ipsilateral upper limb motor-evoked potentials (MEPs) elicited by focal transcranial magnetic stimulation (TMS) were compared in healthy subjects and patients with acute stroke.

METHODS

Sixteen healthy subjects and 25 patients with acute stroke underwent focal TMS at maximum stimulator output over motor and premotor cortices. If present, MEPs evoked in muscles ipsilateral to TMS were analyzed for latency, amplitude, shape, and center of gravity (ie, preferential coil location to elicit them). In stroke patients, possible relationships between early ipsilateral responses and functional outcome at 6 months were sought.

RESULTS

With relaxed or slightly contracting target muscle, maximal TMS over the motor cortex failed to elicit ipsilateral MEPs in the first dorsal interosseous (FDI) or biceps of any of 16 normal subjects. In 5 of 8 healthy subjects tested, ipsilateral MEPs with latencies longer than contralateral MEPs were evoked in FDI muscle (in biceps, 6 of 8 subjects) during strong (>50% maximum) contraction of the target muscle. In 15 of 25 stroke patients, ipsilateral MEPs in the unaffected relaxed FDI (in biceps, 6 of 25 stroke patients) were evoked by stimulation of premotor areas of the affected hemisphere. Their latencies were shorter than those that MEPs evoked in the same muscle by stimulation of the motor cortex of the contralateral unaffected hemisphere. Such responses were never obtained in normal subjects and were mostly observed in patients with subcortical infarcts. Patients harboring these responses had slightly better bimanual dexterity after 6 months.

CONCLUSIONS

Ipsilateral MEPs obtained in healthy individuals and stroke patients have different characteristics and probably different origins. In the former, they are probably conveyed via corticoreticulospinal or corticopropriospinal pathways, whereas in the latter, early ipsilateral MEPs could originate in hyperexcitable premotor areas.

Different ipsilateral representations for distal and proximal movements in the sensorimotor cortex: activation and deactivation patterns

Each hemisphere is known to be also involved in controlling the ipsilateral arm, but with an asymmetry favoring the dominant hemisphere. However, the relative role of primary and secondary motor areas in ipsilateral control is not well defined. We used whole brain functional magnetic resonance imaging in healthy human subjects to differentiate between contributions from primary and secondary areas during discrete unilateral distal finger and proximal shoulder movements. It was found that ipsilateral distal movements activated secondary areas only, while sparing or even significantly deactivating the primary sensorimotor cortex. Ipsilateral proximal movements substantially activated both SM1 and secondary areas. A newly defined small territory within the precentral gyrus, extending from the premotor cortex and intruding toward SM1, showed an activation pattern corresponding to secondary motor areas. Finally, the effects of hemispheric dominance were confirmed, but attributed exclusively to secondary areas. These new imaging findings agree well with functional requirements as well as established anatomical and neurophysiological data.

Bilateral Interactions During Contractions of Intrinsic Hand Muscles

During demanding voluntary contractions (e.g., high force or fatigue), activation is not restricted to the target muscle but extends to other ipsilateral muscles; even contralateral muscles become activated. The contralateral “irradiation” of activity was measured in five subjects during submaximal and maximal voluntary contractions (MVCs) of the first dorsal interosseous (FDI) (index finger abduction) and during unfatigued and fatigued conditions. All subjects were tested five times with at least one week between tests. Unilateral MVCs were associated with a substantial amount of contralateral FDI activation [mean = 7.9 ± 6.7% (SD) MVC prior to fatigue]. The amount of such contralateral irradiation was significantly different between different individuals and was positively correlated between dominant and nondominant hands. During fatigue tests, the contractile activity of the contralateral “nontarget” index finger showed progressive increase (force, electromyogram) as was measured during both the submaximal task and interspersed MVCs of the target finger. In addition, a superimposed saw-tooth pattern of intermittently waxing and waning contractions commonly appeared contralaterally. The expression of contralateral irradiation force was itself fatigue-sensitive: less irradiation was seen in a recently fatigued muscle than was seen before the fatigue test. These fatigue effects could not be explained as having been caused by changes in muscle properties. Possible anatomical sites of contralateral irradiation are briefly discussed.

Hemispheric asymmetry of ipsilateral motor cortex activation during unimanual motor tasks: further evidence for motor dominance

OBJECTIVES

To test to which extent the increase in ipsilateral motor cortex excitability during unimanual motor tasks shows hemispheric asymmetry.

METHODS

Six right-handed healthy subjects performed one of several motor tasks of different complexity (including rest) with one hand (task hand) while the other hand (non-task hand) was relaxed. Focal transcranial magnetic stimulation was applied to the motor cortex ipsilateral to the task hand and the amplitude of the motor evoked potential (MEP) in the non-task hand was measured. In one session, the task hand was the right hand, in the other session it was the left hand. The effects of motor task and side of the task hand were analyzed. Spinal motoneuron excitability was assessed using F-wave measurements.

RESULTS

Motor tasks, in particular complex finger sequences, resulted in an increase in MEP amplitude in the non-task hand. This increase was significantly less when the right hand rather than the left hand was the task hand. This difference was seen only in muscles homologous to primary task muscles. The asymmetry could not be explained by changes in F-wave amplitudes.

CONCLUSIONS

Hemispheric asymmetry of ipsilateral motor cortex activation either supports the idea that, in right handers, the left motor cortex is more active in ipsilateral hand movements, or alternatively, that the left motor cortex exerts more effective inhibitory control over the right motor cortex than vice versa. We suggest that hemispheric asymmetry of ipsilateral motor cortex activation is one property of motor dominance of the left motor cortex.

Ipsilateral activation of the unaffected motor cortex in patients with hemiparetic stroke

BACKGROUND AND PURPOSE

Recent research has shown that following stroke patients can display ipsilateral activity reflecting a functional link between the undamaged hemisphere and the affected upper limb on the same side of the body. In the present study the capacity for ipsilateral activation is documented during recovery by using transcranial magnetic stimulation (TMS) and transcranial Doppler (TCD).

METHODS

Fourteen patients affected by hemispheric stroke were examined with TMS and TCD within 48 h of onset, and again 6 months later. Neurological signs were scored with reference to the NIHSS, and patients executed a thumb to finger opposition task so as to further estimate the motor deficit. Twenty healthy volunteers represented the control population.

RESULTS

(1) Both TMS and TCD yielded homogeneous results showing ipsilateral activity between affected hands and undamaged hemispheres. On stimulating the motor cortex 3 cm anterior and 3 cm lateral to Cz, a scalp site remote from the primary motor area, ipsilateral motor evoked potentials (iMEPs) from hand muscles were found in recovered patients. (2) In 8 controls iMEPs with smaller amplitudes than patients could be obtained by stimulating only the left hemisphere. (3) TCD revealed increased blood flow velocity in the ipsilateral MCA by activating the recovering hand (10.5+/-3.3%; P<0.001).

CONCLUSION

TMS reveals a specific area in the motor cortex from which ipsilateral MEPs can be elicited and both TMS and TCD indicate that an ipsilateral corticospinal tract can be accessible in some adult controls or becomes unmasked after cerebral damage.

Reorganization of the motor cortex in a patient with congenital hemiparesis and mirror movements

Abnormal branching of corticospinal fibers from the unaffected motor cortex is responsible for mirror movements in patients with congenital hemiparesis, but it is unknown which mechanisms enable these patients to lateralize motor activity. Using multiunit electromyographic analysis and transcranial magnetic stimulation, the authors provide evidence for nonbranched crossed and uncrossed corticospinal projections and intracortical inhibition of the mirror hand. They propose that this remarkable reorganization of the unaffected motor cortex helps these patients to reduce mirror movements.