Reproducibility of neurophysiological and myometric measurement in the ulnar nerve-abductor digiti minimi system

Feasibility of magnetomyography with optically pumped magnetometers in a mobile magnetic shield

While magnetomyography (MMG) using optically pumped magnetometers (OPMs) is a promising method for non-invasive investigation of the neuromuscular system, it has almost exclusively been performed in magnetically shielded rooms (MSRs) to date. MSRs provide extraordinary conditions for biomagnetic measurements but limit the widespread adoption of measurement methods due to high costs and extensive infrastructure. In this work, we address this issue by exploring the feasibility of mobile OPM-MMG in a setup of commercially available components. From field mapping and simulations, we find that the employed zero-field OPM can operate within a large region of the mobile shield, beyond which residual magnetic fields and perturbations become increasingly intolerable. Moreover, with digital filtering and moderate averaging a signal quality comparable to that in a heavily shielded MSR is attained. These findings facilitate practical and cost-effective implementations of OPM-MMG systems in clinical practice and research.

Neurophysiological indices in amyotrophic lateral sclerosis correlate with functional outcome measures, staging and disease progression

OBJECTIVE

This study examined neurophysiological (NI), split-hand (SI) and split-leg (SLI) index in patients with amyotrophic lateral sclerosis (ALS), and their correlation with functional status, disease duration, staging and survival.

METHODS

Eighty-two patients underwent nerve conduction study to analyze NI, SI and SLI. Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R), disease progression rate (ΔFS), Milano-Torino (MiToS) and King's staging systems, Forced Vital Capacity (FVC), and survival data were collected.

RESULTS

Both NI and SI indices were significantly associated with ALSFRS-R, MiToS, King's and FVC. Slow progressor patients (ΔFS < 0.5) reported a significantly higher NI and SI values compared to both normal (0.5 ≤ ΔFS < 1.00) and fast progressors (ΔFS ≥ 1.0). After dichotomizing patients in slow progressors (ΔFS < 0.5) and not-slow progressors (ΔFS ≥ 0.5), a combination of SI index and disease duration revealed to be the best prediction model to discriminate patients in accordance with their disease progression (c-index: 0.92), leading to a new prognostic index: the 'Split-Hand prognostic index' (SHpi).

CONCLUSION

SI and NI are correlated with functional status and FVC. SHpi index could represent an useful tool to discriminate patients in accordance with their disease progression.

SIGNIFICANCE

These data provide novel evidence of neurophysiological indices as promising biomarkers in ALS.

Beyond fractional anisotropy in amyotrophic lateral sclerosis: the value of mean, axial, and radial diffusivity and its correlation with electrophysiological conductivity changes

PURPOSE

This paper aims to analyze the contribution of mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) in the detection of microstructural abnormalities in amyotrophic lateral sclerosis (ALS) and to evaluate the degree of agreement between structural and functional changes through concomitant diffusion tensor imaging (DTI), transcranial magnetic stimulation (TMS), and clinical assessment.

METHODS

Fourteen patients with ALS and 11 healthy, age- and gender-matched controls were included. All participants underwent magnetic resonance imaging including DTI. TMS was additionally performed in ALS patients. Differences in the distribution of DTI-derived measures were assessed using tract-based spatial statistical (TBSS) and volume of interest (VOI) analyses. Correlations between clinical, imaging, and neurophysiological findings were also assessed through TBSS.

RESULTS

ALS patients showed a significant increase in AD and MD involving the corticospinal tract (CST) and the pre-frontal white matter in the right posterior limb of the internal capsule (p < 0.05) when compared to the control group using TBSS, confirmed by VOI analyses. VOI analyses also showed increased AD in the corpus callosum (p < 0.05) in ALS patients. Fractional anisotropy (FA) in the right CST correlated significantly with upper motor neuron (UMN) score (r = - 0.79, p < 0.05), and right abductor digiti minimi central motor conduction time was highly correlated with RD in the left posterior internal capsule (r = - 0.81, p < 0.05). No other significant correlation was found.

CONCLUSION

MD, AD, and RD, besides FA, are able to further detect and characterize neurodegeneration in ALS. Furthermore, TMS and DTI appear to have a role as complementary diagnostic biomarkers of UMN dysfunction.

Ulnar Nerve Conduction Block Using Surface Kilohertz Frequency Alternating Current: A Feasibility Study

The aim of this study was to test the effects of kilohertz frequency alternating current (KHFAC) surface stimulation applied to the ulnar nerve on force and myoelectrical activity of the abductor digiti minimi (ADM) muscle. Eighteen healthy volunteers (age: 27.6 ± 7.9 years; 10 males, 8 females) were included in the study. Each subject participated in one session during which a biphasic 7 kHz rectangular pulse was delivered above the medial epicondyle of the humerus to induce ulnar nerve blocking. ADM electromyographic (EMG) activity and contraction force were measured before (Pre), immediately after, and following 5 and 10 min post stimulation (post 1, post 2). The results showed that EMG activity decreased immediately after stimulation compared to prestimulation, it returned to the level of prestimulation at 5 min (post 1), and decreased again at 10 min (post 2). Furthermore, analysis of compound adjusted z-score indicated significant decrease of force and myoelectrical activity immediately, and 10 min post stimulation. The findings, which demonstrate that KHFAC surface stimulation of the ulnar nerve may decrease the motor activity of intrinsic hand muscle, can help to develop future methods of neuromodulation to treat hand spasticity.

Nerve Conduction Studies as a Measure of Disease Progression: Objectivity or Illusion?

BACKGROUND

Clinical nerve conduction studies (NCS) are often used as a secondary outcome measure in therapeutic trials, but show a high degree of inter-trial variability even when technical factors known to affect the recorded responses are minimised. This raises the intriguing possibility that some of the observed variability may reflect true changes in nerve activity.

OBJECTIVES

Our aim was determine how much variability these factors might produce, and how this might affect the results of commonly used neuropathy rating scales.

METHODS

A standardised protocol was repeated over forty consecutive trials by the same operators in two healthy subjects. The protocol included recordings that shared either a stimulating or a recording electrode position, such that changes due to electrode position could be excluded, and hand temperature was closely controlled.

RESULTS

Despite controlling for inter-operator differences, electrode position, and hand temperature, the variability in sensory nerve action potential (SNAP) amplitude was extremely high (Range 23 μV, CoV = 10.7-18.8). This variability was greater than the change in amplitude needed to move a subject from point 0 to point 4 on the CMT neuropathy rating scale. Neither temperature or electrode position accounted for all of this variability, suggesting that additional as yet unidentified factors are responsible.

CONCLUSION

Even under closely controlled conditions and sophisticated laboratory methods, test-to-test variability can be significant. The factors responsible for this variability may be difficult to control, limiting the utility of single nerve recordings as a trial outcome measure.

Neurophysiological approach to disorders of peripheral nerve

Disorders of the peripheral nerve system (PNS) are heterogeneous and may involve motor fibers, sensory fibers, small myelinated and unmyelinated fibers and autonomic nerve fibers, with variable anatomical distribution (single nerves, several different nerves, symmetrical affection of all nerves, plexus, or root lesions). Furthermore pathological processes may result in either demyelination, axonal degeneration or both. In order to reach an exact diagnosis of any neuropathy electrophysiological studies are crucial to obtain information about these variables. Conventional electrophysiological methods including nerve conduction studies and electromyography used in the study of patients suspected of having a neuropathy and the significance of the findings are discussed in detail and more novel and experimental methods are mentioned. Diagnostic considerations are based on a flow chart classifying neuropathies into eight categories based on mode of onset, distribution, and electrophysiological findings, and the electrophysiological characteristics in each type of neuropathy are discussed.

Neurophysiological measures in amyotrophic lateral sclerosis: Markers of progression in clinical trials

In this review we evaluate clinical neurophysiological methods, originally described for use in diagnosis that can be applied to measurement of change during the progress of amyotrophic lateral sclerosis (ALS). Such measurements are potentially important in clinical trials, and also in clinical practice. We have assessed methods for lower and upper motor neuron function, including conventional EMG, nerve conduction and F-wave studies, the derived Neurophysiological Index, motor unit counting methods (MUNE), and transcranial magnetic motor cortex stimulation. We have also addressed the validity of measurements of electromechanical coupling. Methods for measuring muscle strength are beyond the scope of this review. We conclude that MUNE, M-wave amplitude and the Neurophysiological Index are sufficiently reliable, sensitive, and relevant to the clinical problem of ALS, to be used in clinical trials in the disease. Transcranial magnetic stimulation is of limited value, but a combination of the measurements made as part of this technique may also be useful. We conclude that clinical neurophysiological techniques should now be used in measuring change in clinical trials in ALS.

Clinical patterns in progressive muscular atrophy (PMA): A prospective study

Progressive muscular atrophy (PMA) is a form of motor neuron disease, but its outcome is not well defined, and the aim was to study the pattern of clinical progression in PMA. We studied 10 patients prospectively for 12 months. None showed clinical signs of upper motor neuron involvement at presentation or during follow-up, and all had normal transcranial magnetic stimulation studies. Four had upper limb onset, four lower limb onset and two axial onset. We used neurophysiological and strength measurements and a clinical rating scale (ALS-FRS). Seven other patients presenting with a PMA syndrome developed upper motor neuron signs during a one-year period of observation and were excluded from the study. The rate of progression was variable. At six months, only motor unit number estimation (MUNE) and ALS-FRS had decreased significantly. The Neurophysiological Index (NI) and M-wave amplitude measurements decreased at 12 months. Two patients with axial-onset disease progressed rapidly to respiratory failure. Overall the pattern of change resembled that of ALS, although some patients progressed very slowly. Axial onset, however, predicts the early onset of respiratory failure, and a poor prognosis.

Assessment of precision and reproducibility of a new myograph

Background

The physiological characteristics of muscle activity and the assessment of muscle strength represent important diagnostic information. There are many devices that measure muscle force in humans, but some require voluntary contractions, which are difficult to assess in weak or unconscious patients who are unable to complete a full range of voluntary force assessment tasks. Other devices, which obtain standard muscle contractions by electric stimulations, do not have the technology required to induce and measure reproducible valid contractions at the optimum muscle length.

Methods

In our study we used a newly developed diagnostic device which measures accurately the reproducibility and time-changed-variability of the muscle force in an individual muscle. A total of 500 in-vivo measurements of supra-maximal isometric single twitch contractions were carried out on the musculus adductor pollicis of 5 test subjects over 10 sessions, with ten repetitions per session. The same protocol was performed on 405 test subjects with two repetitions each to determine a reference-interval on healthy subjects.

Results

Using our test setting, we found a high reproducibility of the muscle contractions of each test subject. The precision of the measurements performed with our device was 98.74%. Only two consecutive measurements are needed in order to assess a real, representative individual value of muscle force. The mean value of the force of contraction was 9.51 N and the 95% reference interval was 4.77–14.25 N.

Conclusion

The new myograph is a highly reliable measuring device with which the adductor pollicis can be investigated at the optimum length. It has the potential to become a reliable and valid tool for diagnostic in the clinical setting and for monitoring neuromuscular diseases.

Reliability of techniques to assess human neuromuscular function in vivo

The purpose of this study was to comprehensively evaluate the reliability of a large number of commonly utilized experimental tests of in vivo human neuromuscular function separated by 4-weeks. Numerous electrophysiological parameters (i.e., voluntary and evoked electromyogram [EMG] signals), contractile properties (i.e., evoked forces and rates of force development and relaxation), muscle morphology (i.e., MRI-derived cross-sectional area [CSA]) and performance tasks (i.e., steadiness and time to task failure) were assessed from the plantarflexor muscle group in 17 subjects before and following 4-weeks where they maintained their normal lifestyle. The reliability of the measured variables had wide-ranging levels of consistency, with coefficient of variations (CV) ranging from approximately 2% to 20%, and intraclass correlation coefficients (ICC) between 0.53 and 0.99. Overall, we observed moderate to high-levels of reliability in the vast majority of the variables we assessed (24 out of the 29 had ICC>0.70 and CV<15%). The variables demonstrating the highest reliability were: CSA (ICC=0.93-0.98), strength (ICC=0.97), an index of nerve conduction velocity (ICC=0.95), and H-reflex amplitude (ICC=0.93). Conversely, the variables demonstrating the lowest reliability were: the amplitude of voluntary EMG signal (ICC=0.53-0.88), and the time to task failure of a sustained submaximal contraction (ICC=0.64). Additionally, relatively little systematic bias (calculated through the limits of agreement) was observed in these measures over the repeat sessions. In conclusion, while the reliability differed between the various measures, in general it was rather high even when the testing sessions are separated by a relatively long duration of time.

Does caffeine modify corticomotor excitability?

AIMS

To test the influence of caffeine on the lower and upper motor neuron excitability.

METHODS

In Experiment A, 18 healthy subjects received 200 mg of caffeine or placebo, in a randomized, double-blind, placebo-controlled design protocol. Mean F-waves amplitude, amplitude of the motor response evoked by magnetic stimulation (MEP), MEP duration, cortical silent period (CSP), central conduction time, and cortical threshold were evaluated. In Experiment B, 6 healthy controls received 400 mg of caffeine, the peripheral silent period (PSP) and CSP were evaluated. CSP was recorded bilaterally in biceps brachii (intensity 10% above threshold) and abductor digiti minimi (ADM) (intensity at 10% and 50% above threshold). Muscle contraction was above 50% of the maximum force in both experiments. Latencies were defined by a technician who was not aware of this investigation. Serum caffeine level was evaluated.

RESULTS

In Experiment A, only the CSP, recorded in both ADM with intensity at 10% above threshold showed a significant change after caffeine (decrease of 17.1+/-34.0 ms, about 12% reduction). In Experiment B, PSP did not change, but CSP tested with intensities 10% above threshold was significantly decreased by 20.8+/-34.4 ms in ADM and 13.5+/-13.8 ms in biceps (about 13 and 16%, respectively). Serum caffeine level clearly increased after consumption but no correlation could be found between these levels and CSP reduction.

CONCLUSIONS

In our investigation, caffeine elicited a consistent decrease of the CSP, suggesting that caffeine increases cortical neuronal excitability.

Analysis of force profile during a maximum voluntary isometric contraction task

This study analyses maximum voluntary isometric contraction (MVIC) and its measurement by recording the force profile during maximal-effort, 7-s hand-grip contractions. Six healthy subjects each performed three trials repeated at short intervals to study variation from fatigue. These three trials were performed during three separate sessions at daily intervals to look at random variation. A pattern of force development during a trial was identified. An initiation phase, with or without an initiation peak, was followed by a maintenance phase, sometimes with secondary pulses and an underlying decline in force. Of these three MVIC parameters, maximum force during the maintenance phase showed less random variability compared to intertrial fatigue variability than did maximum force during the initiation phase or absolute maximum force. Analysis of MVIC as a task, rather than a single, maximal value reveals deeper levels of motor control in its generation. Thus, force parameters other than the absolute maximum force may be better suited to quantification of muscle performance in health and disease.

Clinical and neurophysiological evaluation of progression in amyotrophic lateral sclerosis

There is a need for a sensitive neurophysiological measure of disease progression in following the course of patients with amyotrophic lateral sclerosis (ALS). We studied two groups of nine ALS patients, one with slow progression (Group A) and the other with rapid progression (Group B). We evaluated muscle strength scores using the Medical Research Council (MRC) scale in limb and trunk muscles, forced vital capacity (FVC), and ALS functional rating scale (ALS-FRS) scores. Maximal voluntary isometric contraction (MVIC) of the abductor digiti minimi muscle (ADM) was measured, using a digital device. We also measured M-wave amplitude and area in the ADM, and the distal motor latency and F-wave frequency in the ulnar nerve; from these data, the neurophysiological index (NI) was calculated, as described previously. In both groups, the NI was the most sensitive measure of change, with the smallest coefficient of variation. We conclude that the NI, which requires no special technology and no new clinical or technical skills to use, is sensitive to change, and therefore may be useful in clinical trials, as well as in a clinical setting.

Motor responses evoked by transcranial magnetic stimulation and peripheral nerve stimulation in the ulnar innervation in amyotrophic lateral sclerosis: the effect of upper and lower motor neuron lesion

We studied the upper (UMN) and lower motor neuron (LMN) innervations of 159 hands from 81 patients with amyotrophic lateral sclerosis (ALS). Eleven patients with various chronic LMN disorders causing weakness in the abductor digiti minimi (ADM) muscle served as LMN controls. Thirty healthy subjects served as normal controls. Cortical motor threshold, central conduction time (CMCT), and motor-evoked response amplitude (MEP) after transcranial magnetic stimulation (TMS) were studied, and the MEP/M wave ratio was calculated. The data was analyzed in the ALS subjects in groups defined by ADM muscle strength and by the presence or absence of clinical signs of UMN involvement. CMCT was not increased in the ALS or LMN disease groups. The threshold was higher in limbs with both weak ADM muscles and UMN signs. The MEP/M wave amplitude ratio was increased in weak muscles in the ALS patients, notably in limbs with no UMN signs, and also in weak muscles in patients with other chronic LMN disorders. It was frequently decreased in strong muscles. There was no difference between bulbar-onset and limb-onset ALS groups, and there was no correlation between threshold and disease duration. We suggest that expressing the data as an index and utilising the MEP/M wave amplitude ratio as a variable is a sensitive method for detecting UMN abnormality in ALS in particular in early affected muscles.

What does the neurologist expect from clinical neurophysiology?

The future role of clinical neurophysiology is considered in the light of its achievements. It is argued that there is a need to develop methods for specific diagnosis, especially in neuropathies. There is also an unmet requirement for the development of techniques for the prediction of treatment outcomes and for the measurement of changes during the natural history of neuromuscular disorders and their treatment. These issues are not addressed by currently available clinical test methods.

Clinical neurophysiology of ALS

The neurophysiology of amyotrophic lateral sclerosis is important not only in relation to diagnosis, but also in the development of methods to follow progress, and the effects of putative therapies, in the disease. Quantitative techniques can be applied to the measurement of reinnervation using needle electromyogram. The methodology of motor unit number estimation may be useful in measuring loss of functioning motor units in groups of patients but variability in the measurement using current methods limits its sensitivity in the evaluation of individual patients. Conventional neurophysiological measurements, expressed as a multimetric index, may be useful in assessing progress. The cortical and upper motor neuron system can be assessed using transcortical magnetic stimulation protocols, and cortical excitability may be measured by the peristimulus histogram method. In this review the advantages, limitations and promise of these various methods is discussed, in order to indicate the direction for further neurophysiological studies in this disorder.