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

The Role of Mirror Therapy in the Rehabilitation of the Upper Limb's Motor Deficits After Stroke: Narrative Review

Stroke is one of the leading causes of death and disability worldwide and poses a tremendous socioeconomic burden upon individuals, countries and healthcare systems. It causes debilitating symptoms and thus interferes with many aspects of the patient's life, including physical functioning, cognition, emotional status, activities of daily living, social reintegration and quality of life. Post-stroke patients frequently experience functional motor disabilities of the upper limb, which restrict autonomy and self-efficacy and cause limitations in engagement with activities and social participation, as well as difficulties in performing important occupations. It is therefore not surprising that motor impairment or loss of motor function of the upper limb is one of the most devastating sequelae of stroke. On these grounds, achieving optimal functioning of the upper limb after stroke remains a fundamental goal of stroke rehabilitation. Mirror therapy (MT) represents one of the several rehabilitation techniques used for restoring the upper limb's motor function after a stroke. However, conflicting results about the role of MT in the rehabilitation of the upper limb's motor deficits have been reported in the literature. Accordingly, the aim of this narrative review is to summarize existing evidence regarding the effects of MT on the upper limb's motor function in post-stroke patients and to further explore its role when applied in different phases of stroke.

Inducing ipsilateral motor-evoked potentials in the biceps brachii muscle in healthy humans

To assess reticulospinal tract excitability, high-intensity transcranial magnetic stimulation (TMS) has been used to elicit ipsilateral motor-evoked potentials (iMEPs). However, there is no consensus on robust and valid methods for use in human studies. The present study proposes a standardized method for eliciting and analysing iMEPs in the biceps brachii. Twenty-four healthy young adults participated in this study. Electromyography (EMG) electrodes recorded contralateral MEPs (cMEPs) from the right and iMEPs from the left biceps brachii. A dynamic preacher curl task was used with ~15% of the subject's one-repetition maximum load. The protocol included maximal compound action potential (M-max) determination of the right biceps brachii muscle, TMS hotspot determination, and four sets of five repetitions where 100% stimulator output was delivered at an elbow angle of 110° of flexion. We normalized cMEP amplitude by M-max (% M-max) and iMEP by cMEP amplitude ratio (ICAR). Clear iMEPs above background EMG were observed in 21 subjects (88%, ICAR = .31 ± .19). Good-to-excellent agreement (intraclass correlation coefficient [ICC] = .795-1.000) and low bias (.01-.08 mV and .60-1.11 ms) were demonstrated when comparing two different analysis methods (i.e. fixed time-window vs. manual onset detection) to determine the cMEP and iMEP amplitude and latency, respectively. Most subjects demonstrated clear iMEPs above background EMG triggered at a pre-determined joint angle during a light-load dynamic preacher curl exercise. Similar results were obtained when comparing a single-trial manual identification of iMEP and a semi-automated time-window data analysis approach.

The excitability of ipsilateral motor evoked potentials is not task-specific and spatially distinct from the contralateral motor hotspot

OBJECTIVE

The role of ipsilateral descending motor pathways in voluntary movement of humans is still a matter of debate, with partly contradictory results. The aim of our study therefore was to examine the excitability of ipsilateral motor evoked potentials (iMEPs) regarding site and the specificity for unilateral and bilateral elbow flexion extension tasks.

METHODS

MR-navigated transcranial magnetic stimulation mapping of the dominant hemisphere was performed in twenty healthy participants during tonic unilateral (iBB), bilateral homologous (bBB) or bilateral antagonistic elbow flexion-extension (iBB-cAE), the map center of gravity (CoG) and iMEP area from BB were obtained.

RESULTS

The map CoG of the ipsilateral BB was located more anterior-laterally than the hotspot of the contralateral BB within the primary motor cortex, with a significant difference in CoG in iBB and iBB-cAE, but not bBB compared to the hotspot for the contralateral BB (each p < 0.05). However, different tasks had no effect on the size of the iMEPs.

CONCLUSION

Our data demonstrated that excitability of ipsilateral and contralateral MEP differ spatially in a task-specific manner suggesting the involvement of different motor networks within the motor cortex.

Strength-trained adults demonstrate greater corticoreticular activation versus untrained controls

The rapid increase in strength following strength-training involves neural adaptations, however, their specific localisation remains elusive. Prior focus on corticospinal responses prompts this study to explore the understudied cortical/subcortical adaptations, particularly cortico-reticulospinal tract responses, comparing healthy strength-trained adults to untrained peers. Fifteen chronically strength-trained individuals (≥2 years of training, mean age: 24 ± 7 years) were compared with 11 age-matched untrained participants (mean age: 26 ± 8 years). Assessments included maximal voluntary force (MVF), corticospinal excitability using transcranial magnetic stimulation (TMS), spinal excitability (cervicomedullary stimulation), voluntary activation (VA) and reticulospinal tract (RST) excitability, utilizing StartReact responses and ipsilateral motor-evoked potentials (iMEPs) for the flexor carpi radialis muscle. Trained participants had higher normalized MVF (6.4 ± 1.1 N/kg) than the untrained participants (4.8 ± 1.3 N/kg) (p = .003). Intracortical facilitation was higher in the strength-trained group (156 ± 49%) (p = .02), along with greater VA (98 ± 3.2%) (p = .002). The strength-trained group displayed reduced short-interval-intracortical inhibition (88 ± 8.0%) compared with the untrained group (69 ± 17.5%) (p < .001). Strength-trained individuals exhibited a greater normalized rate of force development (38.8 ± 10.1 N·s-1/kg) (p < .009), greater reticulospinal gain (2.5 ± 1.4) (p = .02) and higher ipsilateral-to-contralateral MEP ratios compared with the untrained group (p = .03). Strength-trained individuals displayed greater excitability within the intrinsic connections of the primary motor cortex and the RST. These results suggest greater synaptic input from the descending cortico-reticulospinal tract to α-motoneurons in strength-trained individuals, thereby contributing to the observed increase in VA and MVF.

The role of ipsilateral motor network in upper limb movement

The execution of voluntary movements is primarily governed by the cerebral hemisphere contralateral to the moving limb. Previous research indicates that the ipsilateral motor network, comprising the primary motor cortex (M1), supplementary motor area (SMA), and premotor cortex (PM), plays a crucial role in the planning and execution of limb movements. However, the precise functions of this network and its interplay in different task contexts have yet to be fully understood. Twenty healthy right-handed participants (10 females, mean age 26.1 ± 4.6 years) underwent functional MRI scans while performing biceps brachii representations such as bilateral, unilateral flexion, and bilateral flexion-extension. Ipsilateral motor evoked potentials (iMEPs) were obtained from the identical set of participants in a prior study using transcranial magnetic stimulation (TMS) targeting M1 while employing the same motor tasks. The voxel time series was extracted based on the region of interest (M1, SMA, ventral PM and dorsal PM). Directed functinal connectivity was derived from the extracted time series using time-resolved partial directed coherence. We found increased connectivity from left-PMv to both sides M1, as well as right-PMv to both sides SMA, in unilateral flexion compared to bilateral flexion. Connectivity from left M1 to left-PMv, and left-SMA to right-PMd, also increased in both unilateral flexion and bilateral flexion-extension compared to bilateral flexion. However, connectivity between PMv and right-M1 to left-PMd decreased during bilateral flexion-extension compared to unilateral flexion. Additionally, during bilateral flexion-extension, the connectivity from right-M1 to right-SMA had a negative relationship with the area ratio of iMEP in the dominant side. Our results provide corroborating evidence for prior research suggesting that the ipsilateral motor network is implicated in the voluntary movements and underscores its involvement in cognitive processes such as movement planning and coordination. Moreover, ipsilateral connectivity from M1 to SMA on the dominant side can modulate the degree of ipsilateral M1 activation during bilateral antagonistic contraction.

Contribution of neural circuits tested by transcranial magnetic stimulation in corticomotor control of low back muscle: a systematic review

Introduction

Transcranial magnetic stimulation (TMS) is widely used to investigate central nervous system mechanisms underlying motor control. Despite thousands of TMS studies on neurophysiological underpinnings of corticomotor control, a large majority of studies have focused on distal muscles, and little is known about axial muscles (e.g., low back muscles). Yet, differences between corticomotor control of low back and distal muscles (e.g., gross vs. fine motor control) suggest differences in the neural circuits involved. This systematic review of the literature aims at detailing the organisation and neural circuitry underlying corticomotor control of low back muscles tested with TMS in healthy humans.

Methods

The literature search was performed in four databases (CINAHL, Embase, Medline (Ovid) and Web of science) up to May 2022. Included studies had to use TMS in combination with EMG recording of paraspinal muscles (between T12 and L5) in healthy participants. Weighted average was used to synthesise quantitative study results.

Results

Forty-four articles met the selection criteria. TMS studies of low back muscles provided consistent evidence of contralateral and ipsilateral motor evoked potentials (with longer ipsilateral latencies) as well as of short intracortical inhibition/facilitation. However, few or no studies using other paired pulse protocols were found (e.g., long intracortical inhibition, interhemispheric inhibition). In addition, no study explored the interaction between different cortical areas using dual TMS coil protocol (e.g., between primary motor cortex and supplementary motor area).

Discussion

Corticomotor control of low back muscles are distinct from hand muscles. Our main findings suggest: (i) bilateral projections from each single primary motor cortex, for which contralateral and ipsilateral tracts are probably of different nature (contra: monosynaptic; ipsi: oligo/polysynaptic) and (ii) the presence of intracortical inhibitory and excitatory circuits in M1 influencing the excitability of the contralateral corticospinal cells projecting to low back muscles. Understanding of these mechanisms are important for improving the understanding of neuromuscular function of low back muscles and to improve the management of clinical populations (e.g., low back pain, stroke).

The tracts, cytoarchitecture, and neurochemistry of the spinal cord

The human spinal cord can be described using a range of nomenclatures with each providing insight into its structure and function. Here we have comprehensively reviewed the key literature detailing the general structure, configuration of tracts, the cytoarchitecture of Rexed's laminae, and the neurochemistry at the spinal segmental level. The purpose of this review is to detail current anatomical understanding of how the spinal cord is structured and to aid researchers in identifying gaps in the literature that need to be studied to improve our knowledge of the spinal cord which in turn will improve the potential of therapeutic intervention for disorders of the spinal cord.

Altered frontoparietal activity in acoustic startle priming tasks during reticulospinal tract facilitation: An fNIRS study

Background

Because it is one of the important pathways for promoting motor recovery after cortical injury, the function of the reticulospinal tract (RST) has received increasing attention in recent years. However, the central regulatory mechanism of RST facilitation and reduction of apparent response time is not well understood.

Objectives

To explore the potential role of RST facilitation in the acoustic startle priming (ASP) paradigm and observe the cortical changes induced by ASP reaching tasks.

Methods

Twenty healthy participants were included in this study. The reaching tasks were performed with their left and right hands. Participants were instructed to get ready after the warning cue and complete the reach as soon as they heard the Go cue. Half of the testing trials were set as control trials with an 80-dB Go cue. The other half of the trials had the Go cue replaced with 114-dB white noise to evoke the StartleReact effect, inducing reticulospinal tract facilitation. The response of the bilateral sternocleidomastoid muscle (SCM) and the anterior deltoid was recorded via surface electromyography. Startle trials were labeled as exhibiting a positive or negative StartleReact effect, according to whether the SCM was activated early (30-130 ms after the Go cue) or late, respectively. Functional near-infrared spectroscopy was used to synchronously record the oxyhemoglobin and deoxyhemoglobin fluctuations in bilateral motor-related cortical regions. The β values representing cortical responses were estimated via the statistical parametric mapping technique and included in the final analyses.

Results

Separate analyses of data from movements of the left or right side revealed significant activation of the right dorsolateral prefrontal cortex during RST facilitation. Moreover, left frontopolar cortex activation was greater in positive startle trials than in control or negative startle trials during left-side movements. Furthermore, decreased activity of the ipsilateral primary motor cortex in positive startle trials during ASP reaching tasks was observed.

Conclusion

The right dorsolateral prefrontal cortex and the frontoparietal network to which it belongs may be the regulatory center for the StartleReact effect and RST facilitation. In addition, the ascending reticular activating system may be involved. The decreased activity of the ipsilateral primary motor cortex suggests enhanced inhibition of the non-moving side during the ASP reaching task. These findings provide further insight into the SE and into RST facilitation.

Evaluation of signal analysis algorithms for ipsilateral motor-evoked potentials induced by transcranial magnetic stimulation

OBJECTIVE

Evaluating ipsilateral motor-evoked potentials (iMEP) induced by transcranial magnetic stimulation (TMS) is challenging. In healthy adults, isometric contraction is necessary to facilitate iMEP induction; therefore, the signal may be masked by the concurrent muscle activity. Signal analysis algorithms for iMEP evaluation need to be benchmarked and evaluated.

APPROACH

An open analysis toolbox for iMEP evaluation was implemented on the basis of eleven previously reported algorithms, which were all threshold based, and a new template-based method based on data-driven signal decomposition. The reliability and validity of these algorithms were evaluated with a dataset of 4244 iMEP from 55 healthy adults.

MAIN RESULTS

iMEP estimation varies drastically between algorithms. Several algorithms exhibit high reliability, but some appear to be influenced by background activity of muscle preactivation. Especially in healthy subjects, template-based approaches might be more valid than threshold-based ones. Measurement of iMEP persistence requires algorithms that reject some trials as MEP negative. The stricter the algorithms reject trials, the less reliable they generally are. Our evaluation identifies an optimally strict and reliable algorithm.

SIGNIFICANCE

We show different benchmarks and propose application for different use cases.

Corticoreticulospinal tract neurophysiology in an arm and hand muscle in healthy and stroke subjects

KEY POINTS

The corticoreticulospinal tract (CReST) is a descending motor pathway that reorganizes after corticospinal tract (CST) injury in animals. In humans, the pattern of CReST innervation to upper limb muscles has not been carefully examined in healthy individuals or individuals with CST injury. In the present study, we assessed CReST projections to an arm and hand muscle on the same side of the body in healthy and chronic stoke subjects using transcranial magnetic stimulation. We show that CReST connection strength to the muscles differs between healthy and stroke subjects, with stronger connections to the hand than arm in healthy subjects, and stronger connections to the arm than hand in stroke subjects. These results help us better understand CReST innervation patterns in the upper limb, and may point to its role in normal motor function and motor recovery in humans.

ABSTRACT

The corticoreticulospinal tract (CReST) is a major descending motor pathway in many animals, but little is known about its innervation patterns in proximal and distal upper extremity muscles in humans. The contralesional CReST furthermore reorganizes after corticospinal tract (CST) injury in animals, but it is less clear whether CReST innervation changes after stroke in humans. We thus examined CReST functional connectivity, connection strength, and modulation in an arm and hand muscle of healthy (n = 15) and chronic stroke (n = 16) subjects. We delivered transcranial magnetic stimulation to the contralesional hemisphere (assigned in healthy subjects) to elicit ipsilateral motor evoked potentials (iMEPs) from the paretic biceps (BIC) and first dorsal interosseous (FDI) muscle. We operationalized CReST functional connectivity as iMEP presence/absence, CReST projection strength as iMEP size and CReST modulation as change in iMEP size by head rotation. We found comparable CReST functional connectivity to the BICs and FDIs in both subject groups. However, the pattern of CReST connection strength to the muscles diverged between groups, with stronger connections to FDIs than BICs in healthy subjects and stronger connections to BICs than FDIs in stroke subjects. Head rotation modulated only FDI iMEPs of healthy subjects. Our findings indicate that the healthy CReST does not have a proximal innervation bias, and its strong FDI connections may have functional relevance to finger individuation. The reversed CReST innervation pattern in stroke subjects confirms its reorganization after CST injury, and its strong BIC connections may indicate upregulation for particular upper extremity muscles or their functional actions.

Effect of Exercise Involving Standing Weight Shifting to the Nonparetic Side on an Inclined Surface in the Early Phase After a Stroke: A Randomized Controlled Trial

OBJECTIVE

This study aimed to clarify whether an exercise involving weight shifting to the nonparetic side while standing on an inclined surface improves standing balance in the early phase after stroke.

METHODS

This assessor-blinded, randomized controlled trial included people undergoing inpatient rehabilitation at a university hospital. Participants (N = 52) with hemiparesis caused by a stroke were randomly assigned to an experimental group (n = 26) or control group (n = 26). Participants performed a weight-shifting exercise to the nonparetic side using a goal-directed reaching strategy while standing on an inclined surface that was elevated 5 degrees to the nonparetic side in the experimental group or a flat surface in the control group. The reaching exercise was conducted 30 times per day for 5 days. Primary outcome was the Berg Balance Scale. Secondary outcomes were the posturographic examination (static standing and lateral weight shifting to the nonparetic and paretic sides), Trunk Control Test, Trunk Impairment Scale, Functional Ambulation Category, and Functional Independent Measure motor item scores.

RESULTS

Through intention-to-treat analysis, no significant intervention effects were observed between groups on the Berg Balance Scale. A significant intervention effect was observed, however, with the experimental group on the lateral weight shifting to the nonparetic side in the mean percentage bodyweight values and center-of-pressure moving distance and to the paretic side in center-of-pressure moving distance and Functional Ambulation Category. There were no significant interaction effects concerning other outcomes.

CONCLUSION

These results suggest that standing reaching exercises to the nonparetic side while standing on an inclined surface could improve lateral weight-shifting capacity and gait ability in participants in the early poststroke phase.

IMPACT

This intervention should be incorporated into standard treatment programs focusing on the paretic side during early stroke rehabilitation.

Interlimb Transfer of Reach Adaptation Does Not Require an Intact Corpus Callosum: Evidence from Patients with Callosal Lesions and Agenesis

Generalization of sensorimotor adaptation across limbs, known as interlimb transfer, is a well-demonstrated phenomenon in humans, yet the underlying neural mechanisms remain unclear. Theoretical models suggest that interlimb transfer is mediated by interhemispheric transfer of information via the corpus callosum. We thus hypothesized that lesions of the corpus callosum, especially to its midbody connecting motor, supplementary motor, and premotor areas of the two cerebral hemispheres, would impair interlimb transfer of sensorimotor adaptation. To test this hypothesis, we recruited three patients: two rare stroke patients with recent, extensive callosal lesions including the midbody and one patient with complete agenesis. A prismatic adaptation paradigm involving unconstrained arm reaching movements was designed to assess interlimb transfer from the prism-exposed dominant arm (DA) to the unexposed non-dominant arm (NDA) for each participant. Baseline results showed that spatial performance of each patient did not significantly differ from controls, for both limbs. Further, each patient adapted to the prismatic perturbation, with no significant difference in error reduction compared with controls. Crucially, interlimb transfer was found in each patient. The absolute magnitude of each patient’s transfer did not significantly differ from controls. These findings show that sensorimotor adaptation can transfer across limbs despite extensive lesions or complete absence of the corpus callosum. Therefore, callosal pathways connecting homologous motor, premotor, and supplementary motor areas are not necessary for interlimb transfer of prismatic reach adaptation. Such interlimb transfer could be mediated by transcallosal splenium pathways (connecting parietal, temporal and visual areas), ipsilateral cortico-spinal pathways or subcortical structures such as the cerebellum.

The Strength of the Corticospinal Tract Not the Reticulospinal Tract Determines Upper-Limb Impairment Level and Capacity for Skill-Acquisition in the Sub-Acute Post-Stroke Period

Background. Upper-limb impairment in patients with chronic stroke appears to be partly attributable to an upregulated reticulospinal tract (RST). Here, we assessed whether the impact of corticospinal (CST) and RST connectivity on motor impairment and skill-acquisition differs in sub-acute stroke, using transcranial magnetic stimulation (TMS)–based proxy measures. Methods. Thirty-eight stroke survivors were randomized to either reach training 3-6 weeks post-stroke (plus usual care) or usual care only. At 3, 6 and 12 weeks post-stroke, we measured ipsilesional and contralesional cortical connectivity (surrogates for CST and RST connectivity, respectively) to weak pre-activated triceps and deltoid muscles with single pulse TMS, accuracy of planar reaching movements, muscle strength (Motricity Index) and synergies (Fugl-Meyer upper-limb score). Results. Strength and presence of synergies were associated with ipsilesional (CST) connectivity to the paretic upper-limb at 3 and 12 weeks. Training led to planar reaching skill beyond that expected from spontaneous recovery and occurred for both weak and strong ipsilesional tract integrity. Reaching ability, presence of synergies, skill-acquisition and strength were not affected by either the presence or absence of contralesional (RST) connectivity. Conclusion. The degree of ipsilesional CST connectivity is the main determinant of proximal dexterity, upper-limb strength and synergy expression in sub-acute stroke. In contrast, there is no evidence for enhanced contralesional RST connectivity contributing to any of these components of impairment. In the sub-acute post-stroke period, the balance of activity between CST and RST may matter more for the paretic phenotype than RST upregulation per se.

Ipsilateral Motor Evoked Potentials as a Measure of the Reticulospinal Tract in Age-Related Strength Changes

Background: The reticulospinal tract (RST) is essential for balance, posture, and strength, all functions which falter with age. We hypothesized that age-related strength reductions might relate to differential changes in corticospinal and reticulospinal connectivity. Methods: We divided 83 participants (age 20-84) into age groups <50 (n = 29) and ≥50 (n = 54) years; five of which had probable sarcopenia. Transcranial Magnetic Stimulation (TMS) was applied to the left cortex, inducing motor evoked potentials (MEPs) in the biceps muscles bilaterally. Contralateral (right, cMEPs) and ipsilateral (left, iMEPs) MEPs are carried by mainly corticospinal and reticulospinal pathways respectively; the iMEP/cMEP amplitude ratio (ICAR) therefore measured the relative importance of the two descending tracts. Grip strength was measured with a dynamometer and normalized for age and sex. Results: We found valid iMEPs in 74 individuals (n = 44 aged ≥50, n = 29 < 50). Younger adults had a significant negative correlation between normalized grip strength and ICAR (r = -0.37, p = 0.045); surprisingly, in older adults, the correlation was also significant, but positive (r = 0.43, p = 0.0037). Discussion: Older individuals who maintain or strengthen their RST are stronger than their peers. We speculate that reduced RST connectivity could predict those at risk of age-related muscle weakness; interventions that reinforce the RST could be a candidate for treatment or prevention of sarcopenia.

Minimum Electromyographic Burst Duration in Healthy Controls: Implications for Electrodiagnosis in Movement Disorders

Background

Electromyogram (EMG) burst duration can provide additional diagnostic information when investigating hyperkinetic movement disorders, particularly when a functional movement disorder is suspected. It is generally accepted that EMG bursts <50 milliseconds are pathological.

Objective

To reassess minimum physiological EMG burst duration.

Methods

Surface EMG was recorded from face, trunk, and limb muscles in controls (n = 60; ages 19–85). Participants were instructed to generate the briefest possible ballistic movements involving each muscle (40 repetitions) or, in muscles spanning joints, to generate rapid rhythmic alternating movements (20–30 seconds), or both.

Results

We found no effect of age on EMG burst duration. However, EMG burst duration varied significantly between body regions. Rhythmic EMG bursts were shorter than ballistic bursts but only significantly so for lower limbs (P < 0.001). EMG bursts of duration <50 milliseconds were frequently observed, particularly in appendicular muscles.

Conclusion

We present normal reference data for minimum EMG burst duration, which may assist clinical interpretation when investigating hyperkinetic movement disorders.

Cortical Activation During Shoulder and Finger Movements in Healthy Adults: A Functional Near-Infrared Spectroscopy (fNIRS) Study

Characterization of cortical activation patterns during movement of the upper extremity in healthy adults is helpful in understanding recovery mechanisms following neurological disorders. This study explores cortical activation patterns associated with movements of the shoulder and fingers in healthy adults using functional near-infrared spectroscopy (fNIRS). Twelve healthy right-handed participants were recruited. Two motor tasks (shoulder abduction and finger extension) with two different trial lengths (10 s and 20 s) were performed in a sitting position at a rate of 0.5 Hz. The hemodynamic response, as indicated by oxy-hemoglobin (HbO) and deoxy-hemoglobin (HbR), over both hemispheres was acquired using a 54-channel fNIRS system. We found a generalized bilateral cortical activation during both motor tasks with greater activation in the contralateral compared to the ipsilateral primary motor cortex. Particularly in the more medial part of the contralateral hemisphere, significant higher activation was found during the shoulder compared to finger movements. Furthermore, cortical activation patterns are affected not only by motor tasks but also by trial lengths. HbO is more sensitive to detect cortical activation during finger movements in longer trials, while HbR is a better surrogate to capture active areas during shoulder movement in shorter trials. Based on these findings, reporting both HbO and HbR is strongly recommended for future fNIRS studies, and trial lengths should be taken into account when designing experiments and explaining results. Our findings demonstrating distinct cortical activation patterns associated with shoulder and finger movements in healthy adults provide a foundation for future research to study recovery mechanisms following neurological disorders.

Assessing sensorimotor control of the lumbopelvic-hip region using task-based functional MRI

Recent brain imaging studies have suggested that cortical remodeling within sensorimotor regions are associated with persistent low back pain and may be a driving mechanism for the impaired neuromuscular control associated with this condition. This paper outlines a new approach for investigating cortical sensorimotor integration during the performance of small-amplitude lumbopelvic movements with functional MRI. Fourteen healthy right-handed participants were instructed in the lumbopelvic movement tasks performed during fMRI acquisition. Surface electromyography (EMG) collected on 8 lumbopelvic and thigh muscles captured organized patterns of muscle activation during the movement tasks. fMRI data were collected on 10 of 14 participants. Sensorimotor cortical activation across the tasks was identified using a whole brain analysis and further explored with regional analyses of key components of the cortical sensorimotor network. Head motion had low correlation to the tasks (r = -0.101 to 0.004) and head translation averaged 0.98 (0.59 mm) before motion correction. Patterns of activation of the key lumbopelvic and thigh musculature (average amplitude normalized 2-17%) were significantly different across tasks (P > 0.001). Neuroimaging demonstrated activation in key sensorimotor cortical regions that were consistent with motor planning and sensory feedback needed for performing the different tasks. This approach captures the specificity of lumbopelvic sensorimotor control using goal-based tasks (e.g., "lift your hip" vs. "contract your lumbar multifidus to 20% of maximum") performed within the confines of the scanner. Specific patterns of sensorimotor cortex activation appear to capture differences between bilateral and unilateral tasks during voluntary control of multisegmental movement in the lumbopelvic region.NEW & NOTEWORTHY We demonstrated the feasibility of using task-based functional magnetic resonance imaging (fMRI) protocols for acquiring the blood oxygen level-dependent (BOLD) response of key sensorimotor cortex regions during voluntary lumbopelvic movements. Our approach activated lumbopelvic muscles during small-amplitude movements while participants were lying supine in the scanner. Our data supports these tasks can be done with limited head motion and low correlation of head motion to the task. The approach provides opportunities for assessing the role of brain changes in persistent low back pain.

Evidence for normal intracortical inhibitory recruitment properties in cervical dystonia

OBJECTIVE

Dystonia is associated with reduced intracortical inhibition as measured by the cortical silent period (cSP); however, this may be due to abnormal cSP threshold or input-output properties. This study evaluated cSP recruitment properties in people with cervical dystonia (CD).

METHODS

Bilateral electromyographic recordings were collected in the upper trapezius muscle in response to transcranial magnetic stimulation of the left and right primary motor cortex in a group with CD (n = 19) and controls (n = 21). cSP threshold, cSP input-output properties at stimulation intensities from 1 to 1.4x the cSP threshold, ipsilateral silent period duration (iSP) and timing and magnitude of the contralateral and ipsilateral motor evoked potential (MEP) were assessed.

RESULTS

The cSP threshold, input-output properties, and contralateral MEP magnitude were not significantly different between groups (all p > 0.07). Hemispheric symmetry was present in the control group while the CD group had reduced iSP (p < 0.01) and a trend for reduced ipsilateral MEP response (p = 0.053) in the left hemisphere.

CONCLUSIONS

Recruitment properties of intracortical inhibition are similar between control and CD groups. Transcallosal inhibition is asymmetric between hemispheres in people with CD.

SIGNIFICANCE

Evidence of normal intracortical inhibition recruitment properties challenge the commonly held view that cortical inhibition is reduced in dystonia.

Ipsilateral primary motor cortex and behavioral compensation after stroke: a case series study

Arm motor recovery after stroke is mainly attributed to reorganization of the primary motor cortex (M1). While M1 contralateral to the paretic arm (cM1) is critical for recovery, the role of ipsilateral M1 (iM1) is still inconclusive. Whether iM1 activity is related to recovery, behavioral compensation, or both is still far from settled. We hypothesized that the magnitude of iM1 activity in chronic stroke survivors will increase or decrease in direct proportion to the degree that movements of the paretic arm are compensated. Movement kinematics (VICON, Oxford Metrics) and functional MRI data (3T MR system) were collected in 11 patients before and after a 4-week training designed to improve motor control of the paretic arm and decrease compensatory trunk recruitment. Twelve matched controls underwent similar evaluations and training. Relationships between iM1 activity and trunk motion were analyzed. At baseline, patients exhibited increased iM1 activity (p = 0.001) and relied more on trunk movement (p = 0.02) than controls. These two variables were directly and significantly related in patients (r = 0.74, p = 0.01) but not in controls (r = 0.28, p = 0.4). After training, patients displayed a significant reduction in iM1 activity (p = 0.008) and a trend toward decreased trunk use (p = 0.1). The relationship between these two variables remained significant (r = 0.66, p = 0.03) and different from controls (r = 0.26, p = 0.4). Our preliminary results suggest that iM1 may play a role in compensating for brain damage rather than directly gaining control of the paretic arm. However, we recommend caution in interpreting these results until more work is completed.

Effects of sonication parameters on transcranial focused ultrasound brain stimulation in an ovine model

Low-intensity focused ultrasound (FUS) has significant potential as a non-invasive brain stimulation modality and novel technique for functional brain mapping, particularly with its advantage of greater spatial selectivity and depth penetration compared to existing non-invasive brain stimulation techniques. As previous studies, primarily carried out in small animals, have demonstrated that sonication parameters affect the stimulation efficiency, further investigation in large animals is necessary to translate this technique into clinical practice. In the present study, we examined the effects of sonication parameters on the transient modification of excitability of cortical and thalamic areas in an ovine model. Guided by anatomical and functional neuroimaging data specific to each animal, 250 kHz FUS was transcranially applied to the primary sensorimotor area associated with the right hind limb and its thalamic projection in sheep (n = 10) across multiple sessions using various combinations of sonication parameters. The degree of effect from FUS was assessed through electrophysiological responses, through analysis of electromyogram and electroencephalographic somatosensory evoked potentials for evaluation of excitatory and suppressive effects, respectively. We found that the modulatory effects were transient and reversible, with specific sonication parameters outperforming others in modulating regional brain activity. Magnetic resonance imaging and histological analysis conducted at different time points after the final sonication session, as well as behavioral observations, showed that repeated exposure to FUS did not damage the underlying brain tissue. Our results suggest that FUS-mediated, non-invasive, region-specific bimodal neuromodulation can be safely achieved in an ovine model, indicating its potential for translation into human studies.

The unsolved role of heightened connectivity from the unaffected hemisphere to paretic arm muscles in chronic stroke

OBJECTIVE

Ipsilateral connectivity from the non-stroke hemisphere to paretic arm muscles appears to play little role in functional recovery, which instead depends on contralateral connectivity from the stroke hemisphere. Yet the incidence of ipsilateral projections in stroke survivors is often reported to be higher than normal. We tested this directly using a sensitive measure of connectivity to proximal arm muscles.

METHOD

TMS of the stroke and non-stroke motor cortex evoked responses in pre-activated triceps and deltoid muscles of 17 stroke survivors attending reaching training. Connectivity was defined as a clear MEP or a short-latency silent period in ongoing EMG in ≥ 50% of stimulations. We measured reaching accuracy at baseline, improvement after training and upper limb Fugl-Meyer (F-M) score.

RESULTS

Incidence of ipsilateral connections to triceps (47%) and deltoid (58%) was high, but unrelated to baseline reaching accuracy and F-M scores. Instead, these were related to contralateral connectivity from the stroke hemisphere. Absolute but not proportional improvement after training was greater in patients with ipsilateral responses.

CONCLUSIONS

Despite enhanced ipsilateral connectivity, arm function and learning was related most strongly to contralateral pathway integrity from the stroke hemisphere.

SIGNIFICANCE

Further work is needed to decipher the role of ipsilateral connections.

Synergy effects of combined multichannel EMG-triggered electrical stimulation and mirror therapy in subacute stroke patients with severe or very severe arm/hand paresis

BACKGROUND

Neurorehabilitation requires the development of severity-dependent and successful therapies for arm/hand rehabilitation in stroke patients.

OBJECTIVE

To evaluate the effectiveness of adding mirror therapy to bilateral EMG-triggered multi-channel electrostimulation for the treatment of severe arm/hand paresis in stroke patients.

METHODS

The subjects of this randomized, controlled, multicentre study were stroke patients who had suffered their first insult between 1 and 6 months before study start and had severe or very severe arm/hand paresis, as classified by Fugl-Meyer-Assessment. Subjects were randomly allocated to an intervention group (n = 16) or control group (n = 17). Both groups were treated for 3 weeks (5x week, 30 minutes) with bilateral EMG-triggered multi-channel electrostimulation. The intervention group additionally received mirror feedback of the unaffected limb. The primary outcome measure was motor recovery of the upper extremities, as measured by the Fugl-Meyer Assessment.

RESULTS

The Intervention Group with very severe paresis had significantly better motor recovery in total Fugl-Meyer Assessment (p = 0.017) at a medium effect size (Cohen) of d = 0.7, due to a significant recovery of shoulder and elbow function (p = 0.003) in the Fugl-Meyer Assessment Part A subtest. For subjects with severe paresis, additional mirror therapy did not significantly influence outcome.

CONCLUSION

Additional mirror therapy in combination with EMG-triggered multi-channel electrostimulation is therapeutically beneficial for post-acute stroke patients with very severe arm/hand paresis.

Ipsilateral EEG mu rhythm reflects the excitability of uncrossed pathways projecting to shoulder muscles

BACKGROUND

Motor planning, imagery or execution is associated with event-related desynchronization (ERD) of mu rhythm oscillations (8-13 Hz) recordable over sensorimotor areas using electroencephalography (EEG). It was shown that motor imagery involving distal muscles, e.g. finger movements, results in contralateral ERD correlating with increased excitability of the contralateral corticospinal tract (c-CST). Following the rationale that purposefully increasing c-CST excitability might facilitate motor recovery after stroke, ERD recently became an attractive target for brain-computer interface (BCI)-based neurorehabilitation training. It was unclear, however, whether ERD would also reflect excitability of the ipsilateral corticospinal tract (i-CST) that mainly innervates proximal muscles involved in e.g. shoulder movements. Such knowledge would be important to optimize and extend ERD-based BCI neurorehabilitation protocols, e.g. to restore shoulder movements after stroke. Here we used single-pulse transcranial magnetic stimulation (TMS) targeting the ipsilateral primary motor cortex to elicit motor evoked potentials (MEPs) of the trapezius muscle. To assess whether ERD reflects excitability of the i-CST, a correlation analysis between between MEP amplitudes and ipsilateral ERD was performed.

METHODS

Experiment 1 consisted of a motor execution task during which 10 healthy volunteers performed elevations of the shoulder girdle or finger pinching while a 128-channel EEG was recorded. Experiment 2 consisted of a motor imagery task during which 16 healthy volunteers imagined shoulder girdle elevations or finger pinching while an EEG was recorded; the participants simultaneously received randomly timed, single-pulse TMS to the ipsilateral primary motor cortex. The spatial pattern and amplitude of ERD and the amplitude of the agonist muscle's TMS-induced MEPs were analyzed.

RESULTS

ERDs occurred bilaterally during both execution and imagery of shoulder girdle elevations, but were lateralized to the contralateral hemisphere during finger pinching. We found that trapezius MEPs increased during motor imagery of shoulder elevations and correlated with ipsilateral ERD amplitudes.

CONCLUSIONS

Ipsilateral ERD during execution and imagery of shoulder girdle elevations appears to reflect the excitability of uncrossed pathways projecting to the shoulder muscles. As such, ipsilateral ERD could be used for neurofeedback training of shoulder movement, aiming at reanimation of the i-CST.

Interhemispheric interactions between trunk muscle representations of the primary motor cortex

Unilateral arm movements require trunk stabilization through bilateral contraction of axial muscles. Interhemispheric interactions between primary motor cortices (M1) could enable such coordinated contractions, but these mechanisms are largely unknown. Using transcranial magnetic stimulation (TMS), we characterized interhemispheric interactions between M1 representations of the trunk-stabilizing muscles erector spinae at the first lumbar vertebra (ES L1) during a right isometric shoulder flexion. These interactions were compared with those of the anterior deltoid (AD), the main agonist in this task, and the first dorsal interosseous (FDI). TMS over the right M1 elicited ipsilateral silent periods (iSP) in all three muscles on the right side. In ES L1, but not in AD or FDI, ipsilateral motor evoked potential (iMEP) could precede the iSP or replace it. iMEP amplitude was not significantly different whether ES L1 was used to stabilize the trunk or was voluntarily contracted. TMS at the cervicomedullary junction showed that the size of cervicomedullary evoked potential was unchanged during the iSP but increased during iMEP, suggesting that the iSP, but not the iMEP, is due to intracortical mechanisms. Using a dual-coil paradigm with two coils over the left and right M1, interhemispheric inhibition could be evoked at interstimulus intervals of 6 ms in ES L1 and 8 ms in AD and FDI. Together, these results suggest that interhemispheric inhibition is dominant when axial muscles are involved in a stabilizing task. The ipsilateral facilitation could be evoked by ipsilateral or subcortical pathways and could be used depending on the role axial muscles play in the task.NEW & NOTEWORTHY The mechanisms involved in the bilateral coordination of axial muscles during unilateral arm movement are poorly understood. We thus investigated the nature of interhemispheric interactions in axial muscles during arm motor tasks in healthy subjects. By combining different methodologies, we showed that trunk muscles receive both inhibitory and facilitatory cortical outputs during activation of arm muscles. We propose that inhibition may be conveyed mainly through interhemispheric mechanisms and facilitation by subcortical mechanisms or ipsilateral pathways.

Non cell-autonomous role of DCC in the guidance of the corticospinal tract at the midline

DCC, a NETRIN-1 receptor, is considered as a cell-autonomous regulator for midline guidance of many commissural populations in the central nervous system. The corticospinal tract (CST), the principal motor pathway for voluntary movements, crosses the anatomic midline at the pyramidal decussation. CST fails to cross the midline in Kanga mice expressing a truncated DCC protein. Humans with heterozygous DCC mutations have congenital mirror movements (CMM). As CMM has been associated, in some cases, with malformations of the pyramidal decussation, DCC might also be involved in this process in human. Here, we investigated the role of DCC in CST midline crossing both in human and mice. First, we demonstrate by multimodal approaches, that patients with CMM due to DCC mutations have an increased proportion of ipsilateral CST projections. Second, we show that in contrast to Kanga mice, the anatomy of the CST is not altered in mice with a deletion of DCC in the CST. Altogether, these results indicate that DCC controls CST midline crossing in both humans and mice, and that this process is non cell-autonomous in mice. Our data unravel a new level of complexity in the role of DCC in CST guidance at the midline.

The corticospinal tract: Evolution, development, and human disorders

The corticospinal tract (CST) plays a major role in cortical control of spinal cord activity. In particular, it is the principal motor pathway for voluntary movements. Here, we discuss: (i) the anatomic evolution and development of the CST across mammalian species, focusing on its role in motor functions; (ii) the molecular mechanisms regulating corticospinal tract formation and guidance during mouse development; and (iii) human disorders associated with abnormal CST development. A comparison of CST anatomy and development across mammalian species first highlights important similarities. In particular, most CST axons cross the anatomical midline at the junction between the brainstem and spinal cord, forming the pyramidal decussation. Reorganization of the pattern of CST projections to the spinal cord during evolution led to improved motor skills. Studies of the molecular mechanisms involved in CST formation and guidance in mice have identified several factors that act synergistically to ensure proper formation of the CST at each step of development. Human CST developmental disorders can result in a reduction of the CST, or in guidance defects associated with abnormal CST anatomy. These latter disorders result in altered midline crossing at the pyramidal decussation or in the spinal cord, but spare the rest of the CST. Careful appraisal of clinical manifestations associated with CST malformations highlights the critical role of the CST in the lateralization of motor control. © 2016 Wiley Periodicals, Inc. Develop Neurobiol 77: 810-829, 2017.

Are ipsilateral motor evoked potentials subject to intracortical inhibition?

Paired-pulse transcranial magnetic stimulation (TMS) can be used to examine intracortical inhibition in primary motor cortex (M1), termed short-interval intracortical inhibition (SICI). To our knowledge, SICI has only been demonstrated in contralateral motor evoked potentials (MEPs). Ipsilateral MEPs (iMEPs) are assumed to reflect excitability of an uncrossed oligosynaptic pathway, and can sometimes be evoked in proximal upper-limb muscles using high-intensity TMS. We examined whether iMEPs in the biceps brachii (BB) would be suppressed by subthreshold conditioning, therefore demonstrating SICI of iMEPs. TMS was delivered to the dominant M1 to evoke conditioned (C) and nonconditioned (NC) iMEPs in the nondominant BB of healthy participants during weak bilateral elbow flexion. The conditioning stimulus intensities tested were 85%, 100%, and 115% of active motor threshold (AMT), at 2 ms and 4 ms interstimulus intervals (ISI). The iMEP ratio (C/NC) was calculated for each condition to assess the amount of inhibition. Inhibition of iMEPs was present at 2 ms ISI with 100% and 115% AMT (bothP< 0.03), mediated by a reduction in persistence and size (allP< 0.05). To our knowledge, this is the first demonstration of SICI of iMEPs. This technique may be useful as a tool to better understand the role of ipsilateral M1 during functional motor tasks.

Differential involvement of cortical and cerebellar areas using dominant and nondominant hands: An FMRI study

Motor fMRI studies, comparing dominant (DH) and nondominant (NDH) hand activations have reported mixed findings, especially for the extent of ipsilateral (IL) activations and their relationship with task complexity. To date, no study has directly compared DH and NDH activations using an event-related visually guided dynamic power-grip paradigm with parametric (three) forces (GF) in healthy right-handed subjects. We implemented a hierarchical statistical approach aimed to: (i) identify the main effect networks engaged when using either hand; (ii) characterise DH/NDH responses at different GFs; (iii) assess contralateral (CL)/IL-specific and hemisphere-specific activations. Beyond confirming previously reported results, this study demonstrated that increasing GF has an effect on motor response that is contextualised also by the use of DH or NDH. Linear analysis revealed increased activations in sensorimotor areas, with additional increased recruitments of subcortical and cerebellar areas when using the NDH. When looking at CL/IL-specific activations, CL sensorimotor areas and IL cerebellum were activated with both hands. When performing the task with the NDH, several areas were also recruited including the CL cerebellum. Finally, there were hand-side-independent activations of nonmotor-specific areas in the right and left hemispheres, with the right hemisphere being involved more extensively in sensori-motor integration through associative areas while the left hemisphere showing greater activation at higher GF. This study shows that the functional networks subtending DH/NDH power-grip visuomotor functions are qualitatively and quantitatively distinct and this should be taken into consideration when performing fMRI studies, particularly when planning interventions in patients with specific impairments.

Recovery of post stroke proximal arm function, driven by complex neuroplastic bilateral brain activation patterns and predicted by baseline motor dysfunction severity

Objectives: Neuroplastic changes that drive recovery of shoulder/elbow function after stroke have been poorly understood. The purpose of this study was to determine the relationship between neuroplastic brain changes related to shoulder/elbow movement control in response to treatment and recovery of arm motor function in chronic stroke survivors.Methods: Twenty-three chronic stroke survivors were treated with 12 weeks of arm rehabilitation. Outcome measures included functional Magnetic Resonance Imaging (fMRI) for the shoulder/elbow components of reach and a skilled motor function test (Arm Motor Abilities Test, AMAT), collected before and after treatment.Results: We observed two patterns of neuroplastic changes that were associated with gains in motor function: decreased or increased task-related brain activation. Those with significantly better motor function at baseline exhibited a decrease in brain activation in response to treatment, evident in the ipsilesional primary motor and contralesional supplementary motor regions; in contrast, those with greater baseline motor impairment, exhibited increased brain activation in response to treatment. There was a linear relationship between greater functional gain (AMAT) and increased activation in bilateral primary motor, contralesional primary and secondary sensory regions, and contralesional lateral premotor area, after adjusting for baseline AMAT, age, and time since stroke.Conclusions: Recovery of functional reach involves recruitment of several contralesional and bilateral primary motor regions. In response to intensive therapy, the direction of functional brain change (i.e., increase or decrease in task-related brain recruitment) for shoulder/elbow reach components depends on baseline level of motor function and may represent either different phases of recovery or different patterns of neuroplasticity that drive functional recovery.

Task-Based Mirror Therapy Augmenting Motor Recovery in Poststroke Hemiparesis: A Randomized Controlled Trial

BACKGROUND

To establish the effect of the task-based mirror therapy (TBMT) on the upper limb recovery in stroke.

METHODS

A pilot, randomized, controlled, assessor-blinded trial was conducted in a rehabilitation institute. A convenience sample of 33 poststroke (mean duration, 12.5 months) hemiparetic subjects was randomized into 2 groups (experimental, 17; control, 16). The subjects were allocated to receive either TBMT or standard motor rehabilitation-40 sessions (5/week) for a period of 8 weeks. The TBMT group received movements using various goal-directed tasks and a mirror box. The movements were performed by the less-affected side superimposed on the affected side. The main outcome measures were Brunnstrom recovery stage (BRS) and Fugl-Meyer assessment (FMA)-FMA of upper extremity (FMA-UE), including upper arm (FMA-UA) and wrist-hand (FMA-WH).

RESULTS

The TBMT group exhibited highly significant improvement on mean scores of FMA-WH (P < .001) and FMA-UE (P < .001) at postassessment in comparison to the control group. Furthermore, there was a 12% increase in the number of subjects at BRS stage 5 (out of synergy movement) in the experimental group as compared to a 0% rise at the same stage in the control group.

CONCLUSIONS

This pilot trial confirmed the role of TBMT in improving the wrist-hand motor recovery in poststroke hemiparesis. MT using tasks may be used as an adjunct in stroke rehabilitation.

One hand clapping: lateralization of motor control

Lateralization of motor control refers to the ability to produce pure unilateral or asymmetric movements. It is required for a variety of coordinated activities, including skilled bimanual tasks and locomotion. Here we discuss the neuroanatomical substrates and pathophysiological underpinnings of lateralized motor outputs. Significant breakthroughs have been made in the past few years by studying the two known conditions characterized by the inability to properly produce unilateral or asymmetric movements, namely human patients with congenital “mirror movements” and model rodents with a “hopping gait”. Whereas mirror movements are associated with altered interhemispheric connectivity and abnormal corticospinal projections, abnormal spinal cord interneurons trajectory is responsible for the “hopping gait”. Proper commissural axon guidance is a critical requirement for these mechanisms. Interestingly, the analysis of these two conditions reveals that the production of asymmetric movements involves similar anatomical and functional requirements but in two different structures: (i) lateralized activation of the brain or spinal cord through contralateral silencing by cross-midline inhibition; and (ii) unilateral transmission of this activation, resulting in lateralized motor output.

Does locomotor training improve pulmonary function in patients with spinal cord injury?

OBJECTIVES

The aim of this study was to compare the effects of a locomotor training (LT) combined rehabilitation program with a rehabilitation-only program on pulmonary function in spinal cord injury (SCI) patients by investigating spirometric analyses of the patients.

SETTING

Rehabilitation center in Ankara, Turkey.

METHODS

Fifty-two patients (40 male, 12 female) with SCI enrolled in the study. The subjects were divided into two groups: the first group (group A) received both LT and a rehabilitation program and the second group (group B) received only the rehabilitation program for 4 weeks. The LT program was prescribed as three 30-min sessions per week. Pulmonary function was evaluated spirometrically in both groups before and after the rehabilitation program.

RESULTS

The spirometric values of the SCI patients, including forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow rate and vital capacity (VC) and VC%, increased significantly with LT in the first group (all P<0.05). Maximum voluntary ventilation values increased significantly in both groups (both P<0.05).

CONCLUSION

These findings suggest that LT is effective for improving pulmonary function in SCI patients. We also highlight the useful effects of LT, which are likely the result of erect posture, gait and neuroplastic changes that prevent potential complications in SCI patients.

Selective activation of ipsilateral motor pathways in intact humans

It has been proposed that ipsilateral motor pathways play a role in the control of ipsilateral movements and recovery of function after injury. However, the extent to which ipsilateral motor pathways are engaged in voluntary activity in intact humans remains largely unknown. Using transcranial magnetic stimulation over the arm representation of the primary motor cortex, we examined ipsilateral motor-evoked potentials (iMEPs) in a proximal arm muscle during increasing levels of unilateral and bilateral isometric force in a sitting position. We demonstrate that iMEP area and amplitude decreased during bilateral contraction of homonymous (elbow flexor) muscles and increased during bilateral contraction of heteronymous (elbow flexor and extensor) muscles compared with a unilateral contraction, regardless of the level of force tested. To further understand the neuronal inputs involved in the bilateral effects, we examined the contribution from neck afferents projecting onto ipsilateral motor pathways. Medial (away from the muscle tested) and lateral (toward the muscle tested) rotation of the head enhanced bilateral iMEP effects from homonymous and heteronymous muscles, respectively. In contrast, head flexion and extension exerted nonspecific bilateral effects on iMEPs. Intracortical inhibition, in the motor cortex where iMEPs originated, showed modulation compatible with the changes in iMEPs. We conclude that ipsilateral projections to proximal arm muscles can be selectively modulated by voluntary contraction of contralateral arm muscles, likely involving circuits mediating asymmetric tonic neck reflexes acting, at least in part, at the cortical level. The pattern of bilateral actions may represent a strategy to engage ipsilateral motor pathways in a motor behavior.

Task-specific role of ipsilateral pathways: somatosensory evoked potentials during cooperative hand movements

Task-specific neural coupling during cooperative hand movements has been described in healthy volunteers, manifested by bilateral reflex electromyographic responses in forearm muscles following unilateral ulnar nerve stimulation and by task-specific activation of secondary somatosensory cortical areas (S2) in functional MRI. The aim of this study was to investigate the role of sensory input to the ipsilateral and contralateral cortex during a cooperative task. Somatosensory evoked potentials from the ulnar nerve were recorded over the ipsilateral and contralateral cortex during resting and during cooperative and noncooperative hand movements. Ipsilateral potentials with smaller amplitude were present under all conditions in almost all participants. In relation to the resting condition, the amplitudes of both the ipsilateral and the contralateral potential were reduced during the cooperative and the noncooperative tasks. Nevertheless, the reduction in amplitude was similar for the ipsilateral and the contralateral potentials in the noncooperative task, but less on the ipsilateral compared with the contralateral side during the cooperative task. The ratio of ipsilateral/contralateral somatosensory evoked potential amplitude was thus significantly larger during the cooperative task compared with the control task and the resting condition. This indicates a functional role of ipsilateral pathways connecting the cervical spinal cord with the cortex during the cooperative task. These observations favor the idea of a task-specific mediation of sensory input from both hands to the ipsilateral and contralateral hemispheres as the basis of neuronal coupling.

Cortical innervation of the hypoglossal nucleus in the non-human primate (Macaca mulatta)

The corticobulbar projection to the hypoglossal nucleus was studied from the frontal, parietal, cingulate, and insular cortices in the rhesus monkey by using high-resolution anterograde tracers and stereology. The hypoglossal nucleus received bilateral input from the face/head region of the primary (M1), ventrolateral pre- (LPMCv), supplementary (M2), rostral cingulate (M3), and caudal cingulate (M4) motor cortices. Additional bilateral corticohypoglossal projections were found from the dorsolateral premotor cortex (LPMCd), ventrolateral proisocortical motor area (ProM), ventrolateral primary somatosensory cortex (S1), rostral insula, and pregenual region of the anterior cingulate gyrus (areas 24/32). Dense terminal projections arose from the ventral region of M1, and moderate projections from LPMCv and rostral part of M2, with considerably fewer hypoglossal projections arising from the other cortical regions. These findings demonstrate that extensive regions of the non-human primate cerebral cortex innervate the hypoglossal nucleus. The widespread and bilateral nature of this corticobulbar connection suggests recovery of tongue movement after cortical injury that compromises a subset of these areas, may occur from spared corticohypoglossal projection areas located on the lateral, as well as medial surfaces of both hemispheres. Since functional imaging studies have shown that homologous cortical areas are activated in humans during tongue movement tasks, these corticobulbar projections may exist in the human brain.

Anodal transcranial direct current stimulation of the motor cortex induces opposite modulation of reciprocal inhibition in wrist extensor and flexor

Transcranial direct current stimulation (tDCS) is used as a noninvasive tool to modulate brain excitability in humans. Recently, several studies have demonstrated that tDCS applied over the motor cortex also modulates spinal neural network excitability and therefore can be used to explore the corticospinal control acting on spinal neurons. Previously, we showed that reciprocal inhibition directed to wrist flexor motoneurons is enhanced during contralateral anodal tDCS, but it is likely that the corticospinal control acting on spinal networks controlling wrist flexors and extensors is not similar. The primary aim of the study was to explore the effects of anodal tDCS on reciprocal inhibition directed to wrist extensor motoneurons. To further examine the supraspinal control acting on the reciprocal inhibition between wrist flexors and extensors, we also explored the effects of the tDCS applied to the ipsilateral hand motor area. In healthy volunteers, we tested the effects induced by sham and anodal tDCS on reciprocal inhibition pathways innervating wrist muscles. Reciprocal inhibition directed from flexor to extensor muscles and the reverse situation, i.e., reciprocal inhibition, directed from extensors to flexors were studied in parallel with the H reflex technique. Our main finding was that contralateral anodal tDCS induces opposing effects on reciprocal inhibition: it decreases reciprocal inhibition directed from flexors to extensors, but it increases reciprocal inhibition directed from extensors to flexors. The functional result of these opposite effects on reciprocal inhibition seems to favor wrist extension excitability, suggesting an asymmetric descending control onto the interneurons that mediate reciprocal inhibition.

Respiratory motor control disrupted by spinal cord injury: mechanisms, evaluation, and restoration

Pulmonary complications associated with persistent respiratory muscle weakness, paralysis, and spasticity are among the most important problems faced by patients with spinal cord injury when lack of muscle strength and disorganization of reciprocal respiratory muscle control lead to breathing insufficiency. This review describes the mechanisms of the respiratory motor control and its change in individuals with spinal cord injury, methods by which respiratory function is measured, and rehabilitative treatment used to restore respiratory function in those who have experienced such injury.

Locomotor step training with body weight support improves respiratory motor function in individuals with chronic spinal cord injury

This prospective case-controlled clinical study was undertaken to investigate to what extent the manually assisted treadmill stepping locomotor training with body weight support (LT) can change respiratory function in individuals with chronic spinal cord injury (SCI). Pulmonary function outcomes (forced vital capacity /FVC/, forced expiratory volume one second /FEV1/, maximum inspiratory pressure /PImax/, maximum expiratory pressure /PEmax/) and surface electromyographic (sEMG) measures of respiratory muscles activity during respiratory tasks were obtained from eight individuals with chronic C3-T12 SCI before and after 62±10 (mean±SD) sessions of the LT. FVC, FEV1, PImax, PEmax, amount of overall sEMG activity and rate of motor unit recruitment were significantly increased after LT (p<0.05). These results suggest that these improvements induced by the LT are likely the result of neuroplastic changes in spinal neural circuitry responsible for the activation of respiratory muscles preserved after injury.

Modulation of transcallosal inhibition by bilateral activation of agonist and antagonist proximal arm muscles

Transcallosal inhibitory interactions between proximal representations in the primary motor cortex remain poorly understood. In this study, we used transcranial magnetic stimulation to examine the ipsilateral silent period (iSP; a measure of transcallosal inhibition) in the biceps and triceps brachii during unilateral and bilateral isometric voluntary contractions. Healthy volunteers performed 10% of maximal isometric voluntary elbow flexion or extension with one arm while the contralateral arm remained at rest or performed 30% of maximal isometric voluntary elbow flexion or extension. The iSP was measured in the arm performing 10% contractions, and electromyographic (EMG) recordings were comparable across conditions. The iSP onset and duration in the biceps and triceps brachii were comparable. In both muscles, the iSP depth and area were increased during bilateral contractions of homologous agonist muscles (extension-extension and flexion-flexion) compared with a unilateral contraction, whereas during bilateral contractions of nonhomologous antagonist muscles (extension-flexion and flexion-extension), the iSP depth and area were decreased compared with a unilateral contraction, and sometimes facilitation of EMG was seen. This effect was never observed during bilateral activation of homologous muscles. The size of responses evoked by cervicomedullary electrical stimulation in the arm that made 10% contractions remained unchanged across conditions. Thus transcallosal inhibition targeting triceps and biceps brachii is upregulated by voluntary contraction of the contralateral agonist muscle and downregulated by voluntary contraction of the contralateral antagonist muscle. We speculate that these reciprocal task-dependent interactions between bilateral flexor and extensor arm regions of the motor cortex may contribute to coupling between the arms during motor behavior.

Does interhemispheric communication relate to the bilateral function of muscles? A study of scapulothoracic muscles using transcranial magnetic stimulation

Interhemispheric connections have been demonstrated between the motor cortex controlling muscle pairs. However, these investigations have tended to concentrate upon hand muscles. We have extended these investigations to proximal muscles that control the scapula upon the trunk and help to move and stabilise the shoulder. Using a paired pulse transcranial magnetic stimulation protocol, the interhemispheric interactions between different shoulder girdle muscle pairs, serratus anterior, upper trapezius and lower trapezius were investigated. Test motor evoked potentials were conditioned using conditioning pulse intensities of 80% and 120% of active motor threshold at three different condition-test intervals, during three different tasks. Interhemispheric inhibition was observed in upper trapezius using a conditioning intensity of 120% and condition-test interval of 8 ms (17 ± 18%, p < 0.007). A trend towards inhibition was observed in lower trapezius and serratus anterior using a conditioning intensity of 120% and a condition-test interval of 8 ms (13 ± 22%; p < 0.07 and 10 ± 19% respectively; p < 0.07). No interhemispheric facilitation was evoked. The study demonstrates that a low level of interhemispheric inhibition rather than interhemispheric facilitation could be evoked between these muscle pairs.

Recruitment of ipsilateral and contralateral upper limb muscles following stimulation of the cortical motor areas in the monkey

It is well established that cortical motor stimulation results in contralateral upper limb (UL) activity. Motor responses are also elicited in the ipsilateral UL, though controversy surrounds the significance of these effects. Evidence suggests that ipsilateral muscle activity is more common following the stimulation of the supplementary motor area (SMA) and dorsal premotor area (PMd), compared to the primary motor cortex (M1), but none of these studies compared effects from all three areas in the same subjects. This has limited our understanding of how these three cortical motor areas influence ipsilateral UL muscle activity. The purpose of this study was to determine the contribution of each of three cortical areas to the production of ipsilateral and contralateral UL. To maximize sensitivity and allow comparison of the effects across cortical areas, we applied the same stimulation parameters (36 pulse stimulus train at 330 Hz) to M1, SMA, and PMd in three adult M. fascicularis and recorded electromyographic (EMG) activity from muscles in the trunk and both ULs. Of all muscle responses identified, 24 % were ipsilateral to the stimulation, mostly in proximal muscles. The highest percentage of ipsilateral responses occurred following SMA stimulation. We also observed that PMd stimulation elicited more suppression responses compared with stimulation of M1 and SMA. The results indicate that ipsilateral motor areas provide a significant contribution to cortical activation of the trunk and proximal UL muscles. These understudied pathways may represent a functional substrate for future strategies to shape UL recovery following injury or stroke.

Pilot comparative study of unilateral and bilateral robot-assisted training on upper-extremity performance in patients with stroke

We compared a unilateral robot-assisted training protocol (URTP) and a bilateral robot-assisted training protocol (BRTP) to study their differential effects. We recruited 21 patients with stroke who received 90-105 min of therapy 5 days/wk for 4 wk. Participants in the URTP and BRTP groups practiced forearm pronation and supination and wrist flexion and extension in a simultaneous manner with the Bi-Manu-Track. The control group received standard rehabilitation. Clinical measures included the Fugl-Meyer Assessment, the Medical Research Council instrument, grip strength, and the Modified Ashworth Scale to assess motor impairment, muscle power, muscle strength, and spasticity, respectively. The pilot study indicated that the URTP and BRTP might have differential benefits for movement improvement. URTP might be a more compelling approach to improving upper-limb motor impairment, muscle power, and strength at the distal joints than BRTP, whereas BRTP could be an optimal approach to improving proximal muscle power.

Unilateral extradural motor cortex stimulation is safe and improves Parkinson disease at 1 year

BACKGROUND

The primary motor cortex, which is part of the corticobasal ganglia loops, may be an alternative option for the surgical treatment of Parkinson disease.

OBJECTIVE

To report on the 1-year safety and efficacy of unilateral extradural motor cortex stimulation in Parkinson disease.

METHODS

A quadripolar electrode strip was extradurally implanted over the motor cortex. Stimulation was continuously delivered through the electrode paddle contralateral to the most affected clinical side. Subjects were prospectively evaluated by the Unified Parkinson's Disease Rating Scale (UPDRS) and the Parkinson's Disease Quality of Life Questionnaire. In addition, an extensive cognitive and behavioral assessment and electroencephalogram recording were performed.

RESULTS

Nine patients were included in this study. No surgical complications or adverse events occurred. Moreover, no cognitive or behavioral changes were observed. Under the off-medication condition, the UPDRS III at baseline was decreased by 14.1%, 23.3%, 19.9%, and 13.2%, at 1, 3, 6, and 12 months, respectively. The motor effects were bilateral, appeared after 3 to 4 weeks of stimulation, and outlasted the stimulation itself for 3 to 4 weeks in 1 case of stimulator accidental switching off. The UPDRS IV was decreased by 40.8%, 42.1%, and 35.5% at 1, 3, and 12 months, respectively. The scores on the Parkinson's Disease Quality of Life Questionnaire were increased at months 3, 6, and 12.

CONCLUSION

Extradural motor cortex stimulation is a safe procedure. After 12 months, the patients demonstrated a moderate improvement of motor symptoms (particularly axial symptoms) and quality of life.

Effects of mirror therapy on motor and sensory recovery in chronic stroke: a randomized controlled trial

OBJECTIVE

To compare the effects of mirror therapy (MT) versus control treatment (CT) on movement performance, motor control, sensory recovery, and performance of activities of daily living in people with chronic stroke.

DESIGN

Single-blinded, randomized controlled trial.

SETTING

Four hospitals.

PARTICIPANTS

Outpatients with chronic stroke (N=33) with mild to moderate motor impairment.

INTERVENTIONS

The MT group (n=16) received upper extremity training involving repetitive bimanual, symmetrical movement practice, in which the individual moves the affected limb while watching the reflective illusion of the unaffected limb's movements from a mirror. The CT group received task-oriented upper extremity training. The intensity for both groups was 1.5 hours/day, 5 days/week, for 4 weeks.

MAIN OUTCOME MEASUREMENTS

The Fugl-Meyer Assessment; kinematic variables, including reaction time, normalized movement time, normalized total displacement, joint recruitment, and maximum shoulder-elbow cross-correlation; the Revised Nottingham Sensory Assessment; the Motor Activity Log; and the ABILHAND questionnaire.

RESULTS

The MT group performed better in the overall (P=.01) and distal part (P=.04) Fugl-Meyer Assessment scores and demonstrated shorter reaction time (P=.04), shorter normalized total displacement (P=.04), and greater maximum shoulder-elbow cross-correlation (P=.03). The Revised Nottingham Sensory Assessment temperature scores improved significantly more in the MT group than in the CT group. No significant differences on the Motor Activity Log and the ABILHAND questionnaire were found immediately after MT or at follow-up.

CONCLUSIONS

The application of MT after stroke might result in beneficial effects on movement performance, motor control, and temperature sense, but may not translate into daily functions in the population with chronic stroke.

Looking at eye dominance from a different angle: is sighting strength related to hand preference?

Sighting dominance (the behavioural preference for one eye over the other under monocular viewing conditions) has traditionally been thought of as a robust individual trait. However, Khan and Crawford (2001) have shown that, under certain viewing conditions, eye preference reverses as a function of horizontal gaze angle. Remarkably, the reversal of sighting from one eye to the other depends on which hand is used to reach out and grasp the target. Their procedure provides an ideal way to measure the strength of monocular preference for sighting, which may be related to other indicators of hemispheric specialisation for speech, language and motor function. Therefore, we hypothesised that individuals with consistent side preferences (e.g., right hand, right eye) should have more robust sighting dominance than those with crossed lateral preferences. To test this idea, we compared strength of eye dominance in individuals who are consistently right or left sided for hand and foot preference with those who are not. We also modified their procedure in order to minimise a potential image size confound, suggested by Banks et al. (2004) as an explanation of Khan and Crawford's results. We found that the sighting dominance switch occurred at similar eccentricities when we controlled for effects of hand occlusion and target size differences. We also found that sighting dominance thresholds change predictably with the hand used. However, we found no evidence for relationships between strength of hand preference as assessed by questionnaire or by pegboard performance and strength of sighting dominance. Similarly, participants with consistent hand and foot preferences did not show stronger eye preference as assessed using the Khan and Crawford procedure. These data are discussed in terms of indirect relationships between sighting dominance, hand preference and cerebral specialisation for language and motor control.