Bilateral hemispheric control of foot distal movements: evidence from normal subjects

Repetitive Transcranial Magnetic Stimulation With H-Coil Coupled With Cycling for Improving Lower Limb Motor Function After Stroke: An Exploratory Study

BACKGROUND/OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) has been recognized as a promising intervention for the treatment of post-stroke motor deficits. Here, we explore safety, feasibility, and potential effectiveness of high-frequency rTMS (HF-rTMS) delivered with the Hesed coil (H-coil) during active cycling on paretic lower extremity (LE) motor function in chronic stroke.

MATERIALS AND METHODS

Twelve subjects with a first-ever stroke were recruited in this double-blind, placebo controlled, crossover study. Eleven sessions of HF-rTMS (40 2s-trains of 20 Hz at 90% resting leg motor threshold) were delivered over the LE motor areas using the H-coil during active cycling for three weeks. Each subject underwent both real and sham rTMS treatments separated by a four-week washout period, in a random sequence. Vital signs were recorded before and after each rTMS session. Any discomfort related to stimulation and side effects were recorded. LE function was also evaluated with Fugl-Meyer assessment (FMA-LE), spasticity was assessed with modified-Ashworth scale and measures of gait speed and endurance (10-meter and 6-min walk tests, respectively) were recorded.

RESULTS

No participant reported serious adverse effects. During real rTMS, 4 of 12 subjects reported mild side effects including transitory dizziness and muscle twitches on shoulder, so that intensity of stimulation initially set at 90% of RMT was reduced to 80% of RMT on average in these four subjects. Only real treatment was associated with a significant and sustained improvement in FMA-LL (67% responders vs. 9% of the sham). Spasticity significantly ameliorated only after the real rTMS. Real treatment did not offer advantages on walking timed measures when compared with sham.

CONCLUSIONS

This exploratory study suggests that bilateral HF-rTMS combined with cycling is safe and potentially effective in ameliorating paretic LE motor function and spasticity, rather than gait speed or endurance, in chronic stroke.

Vision of the body improves inter-hemispheric integration of tactile-motor responses

Sensory input from and motor output to the two sides of the body needs to be continuously integrated between the two cerebral hemispheres. This integration can be measured through its cost in terms of processing speed. In simple detection tasks, reaction times (RTs) are faster when stimuli are presented to the side of the body ipsilateral to the body part used to respond. This advantage - the contralateral-ipsilateral difference (also known as the crossed-uncrossed difference: CUD) - is thought to reflect inter-hemispheric interactions needed for sensorimotor information to be integrated between the two hemispheres. Several studies have shown that non-informative vision of the body enhances performance in tactile tasks. However, it is unknown whether the CUD can be similarly affected by vision. Here, we investigated whether the CUD is modulated by vision of the body (i.e., the stimulated hand) by presenting tactile stimuli unpredictably on the middle fingers when one hand was visible (i.e., either the right or left hand). Participants detected the stimulus and responded as fast as possible using either their left or right foot. Consistent with previous results, a clear CUD (5.8ms) was apparent on the unseen hand. Critically, however, no such effect was found on the hand that was visible (-2.2ms). Thus, when touch is delivered to a seen hand, the usual cost in processing speed of responding with a contralateral effector is eliminated. This result suggests that vision of the body improves the interhemispheric integration of tactile-motor responses.

Inter-hemispheric integration of tactile-motor responses across body parts

In simple detection tasks, reaction times (RTs) are faster when stimuli are presented to the visual field or side of the body ipsilateral to the body part used to respond. This advantage, the crossed-uncrossed difference (CUD), is thought to reflect inter-hemispheric interactions needed for sensorimotor information to be integrated between the two cerebral hemispheres. However, it is unknown whether the tactile CUD is invariant when different body parts are stimulated. The most likely structure mediating such processing is thought to be the corpus callosum (CC). Neurophysiological studies have shown that there are denser callosal connections between regions that represent proximal parts of the body near the body midline and more sparse connections for regions representing distal extremities. Therefore, if the information transfer between the two hemispheres is affected by the density of callosal connections, stimuli presented on more distal regions of the body should produce a greater CUD compared to stimuli presented on more proximal regions. This is because interhemispheric transfer of information from regions with sparse callosal connections will be less efficient, and hence slower. Here, we investigated whether the CUD is modulated as a function of the different body parts stimulated by presenting tactile stimuli unpredictably on body parts at different distances from the body midline (i.e., Middle Finger, Forearm, or Forehead of each side of the body). Participants detected the stimulus and responded as fast as possible using either their left or right foot. Results showed that the magnitude of the CUD was larger on the finger (~2.6 ms) and forearm (~1.8 ms) than on the forehead (≃0.9 ms). This result suggests that the interhemispheric transfer of tactile stimuli varies as a function of the strength of callosal connections of the body parts.

Noninvasive Neuromodulation in Poststroke Gait Disorders

Walking rehabilitation is one of the primary goals in stroke survivors because of its great potential for recovery and its functional relevance in daily living activities. Although 70% to 80% of people in the chronic poststroke phases are able to walk, impairment of gait often persists, involving speed, endurance, and stability. Walking involves several brain regions, such as the sensorimotor cortex, supplementary motor area, cerebellum, and brainstem, which are approachable by the application of noninvasive brain stimulation (NIBS). NIBS techniques, such as repetitive transcranial magnetic stimulation and transcranial direct current stimulation, have been reported to modulate neural activity beyond the period of stimulation, facilitating neuroplasticity. NIBS methods have been largely applied for improving paretic hand motor function and stroke-associated cognitive deficits. Recent studies suggest a possible effectiveness of these techniques also in the recovery of poststroke gait disturbance. This article is a selective review about functional investigations addressing the mechanisms of lower-limb motor system reorganization after stroke and the application of NIBS for neurorehabilitation.

Lower extremity response time performance in boys with ADHD

OBJECTIVE

Children with ADHD have been labeled as "uncoordinated" and "inefficient movers"; however, a paucity of research has systematically examined "stimulant-free" motor processing in this population.

METHOD

In the present investigation, the authors employ a cross-lateral integration task to assess the attainment of a motor milestone in a corpus of 16 adolescents with ADHD acutely removed from their daily medication routine (methylphenidate) and 19 age-matched peers. Participants perform a choice response time task involving the lower extremity to targets located at midline and in ipsilateral and contralateral space.

RESULTS/CONCLUSION

This investigation finds that children with ADHD have slower lower extremity reaction and movement times compared to controls, and all preadolescent children demonstrate an inhibition in processing movements that require crossing the midline of the body.

Ageing and midline crossing inhibition

Age-related deficits of lower extremity lateral movements were investigated to identify a specific age range for the reappearance of midline crossing inhibition (MCI) along a developmental continuum. Ten individuals (five men and five women) representing each decade between the ages of 40 and 89 (five age groups) performed 108 seated trials on a lower extremity apparatus that measured choice reaction time and movement time. Midline crossing inhibition was operationally defined as statistically slower contralateral reaction times when compared to ipsilateral reaction times. The two eldest age groups (70- and 80-year-olds) exhibited MCI only on the first day of testing. Practice may facilitate cross lateral integration in normal ageing adults, even those of advanced age. There were no significant differences for movement times across age groups.

Experimental disentangling of spatial-compatibility and interhemispheric-relay effects in simple reaction time (Poffenberger paradigm)

Spatial-compatibility effects can be obtained in simple reaction time (SRT) provided that spatially distinct responses are frequently required. Since this effect is limited to trials with relatively long reaction times (RTs), Hommel (1996b) proposed that if the response does not occur shortly after stimulus detection, then the spatial code of the stimulus can interfere with that of the response. A series of experiments is reported showing that (a) spatial compatibility in SRT to lateralized stimuli is not an alternative, but rather a complementary, explanation to interhemispheric transfer time (contrary to what Hommel surmised), and (b) the spatial compatibility component is essentially limited to the first trial after shifting response preparation from one-half of the visual fields to the other, suggesting a mechanism akin to an orienting response.

Hemispheric asymmetry and interhemispheric transfer in pointing depend on the spatial components of the movement

The purpose of the present study was to compare the asymmetry and transfer in 3 pointing movements with increasing spatial requirements. The triggering signal was one of four visual targets appearing on the right or left of a central fixation point (FP). The first task consisted in simply removing the arm from the starting platform; the second was a pointing movement towards the FP, and the third was a classical pointing task towards one of the four lateral targets. 20 right-handers (Rhrs) and 20 left-handers (Lhrs) participated in this experiment. In the classical pointing task (task 3), the reaction times were shorter in the Rhrs using their left hand. No such hand-related difference was observed in the Lhrs. No hand asymmetry was observed in the other tasks. In addition, the responses were faster in the uncrossed than in the crossed conditions, in task 3 only. It was concluded that in pointing tasks, both the hemispheric asymmetry and the interhemispheric transfer depend on the spatial requirements of the movement.

Right hemispheric contribution to motor programming of simultaneous bilateral response

The purpose of this study was to verify the hypothesis that the motor program which integrates the left- and right-hand responses in the bilateral reaction time (RT) task is located in the right hemisphere. 8 female and 50 male students performed bilateral simultaneous RT tasks to lateralized light stimuli. Uncrossed RT based on the relationship between the unifying center in the right hemisphere and hemifield stimulus was shorter than crossed RT for the bilateral response. Therefore, the hypothesis was supported. Some areas of the right hemisphere contributed to unification of the movements of the right and left hands for bilateral movements in reaction time.

The "Poffenberger" and "Dimond" paradigms: interrelated approaches to the study of interhemispheric dynamics?

Brown and Jeeves (1993) found that an evoked potential estimate of interhemispheric transfer time, from the left to the right hemisphere, correlated negatively with a bilateral field advantage (BFA) in a response-choice letter matching task. We implemented a go no-go dot size matching task to determine whether the crossed-uncrossed difference (CUD) in reaction time, commission errors and omission errors (estimates of the "cost" of interhemispheric transfer) would correlate with BFAs in data from the same experiment and whether the type of decision ("same" versus "different") would modulate the CUDs and/or BFAs. Sixteen normal right-handed subjects were tested. The CUDs were negatively correlated with the BFAs. Canonical correlation analysis of this set of relations was highly significant (r = .95). Estimates of left-to-right relay were far more strongly related to BFA (p = .0001) than were estimates of right-to-left relay (p = .03). "Same" decisions yielded a unilateral field advantage and "different" decisions a bilateral field advantage in omission error data, this crossed interaction reaching significance. More efficient interhemispheric relay favored BFAs, i.e., strongly suggesting in such cases an advantage of interhemispheric over intrahemispheric integration. This effect appeared to be markedly asymmetric. Furthermore, resource sharing within and between the hemispheres was a function of the "same" versus "different" dimensions of the decision to be made, especially in omission errors. The opposite dissociation occurred less markedly in the reaction times, this double dissociation reaching significance, revealing presence of a subtle speed-accuracy trade-off in interhemispheric dynamics.

Interhemispheric transfer time differences related to aging and gender

The difference in simple reaction times to unstructured stimuli contralateral to the hand used for response ('crossed' responses) and those stimuli ipsilateral to the hand used for response ('uncrossed' responses)--or crossed-uncrossed difference (CUD) is assumed to be a reliable index of interhemispheric transfer time (IHTT). Studies using the CUD paradigm with acallosal patients as well as a variety of populations with known variations in callosal size or functioning have demonstrated that such callosal differences are reflected in differences in recorded CUD times. Recent studies have suggested that elderly individuals show a reduction in size of the corpus callosum, particularly in the anterior region. In order to assess any potential change in callosal transfer efficiency with aging. CUDs were obtained from elderly (60+ years) and younger subjects (18 30 years). The elderly subjects showed a significantly elongated CUD compared to younger subjects, with elderly females contributing the greatest increase. No significant gender differences were found for younger subjects. In addition, an unexpected trend for an overall right field reaction time advantage was found for all subgroups, accompanied by a larger calculated CUD for right hand responses than for left hand responses.

Callosotomy for intractable epilepsy from bihemispheric cortical dysplasias

Four patients suffering for severe drug-resistant epilepsy from bihemispheric cortical dysplasias underwent anterior callosotomy. One of these patients also presented mental retardation of mild degree associated with the epileptic syndrome. There were no operative complications in this series. Clinical signs of interhemispheric disconnection were not detectable postoperatively. Twenty-eight to 53 months after surgery, the generalized seizures were completely suppressed in 2 cases, and were reduced by 89-97% in frequency in the other 2 cases. Partial seizures were less affected by callosotomy being reduced by 14-87%. In an additional fifth case of intractable epilepsy from bihemispheric cortical dysplasias with associated severe mental retardation operated upon elsewhere for callosotomy and followed at our institution, the outcome for seizures was completely unsatisfactory. Neurophysiological studies revealed that the interhemispheric transfer (IHT) of visuo-motor responses was functionally impaired after callosotomy only in one patient who harboured bilateral cortical dysplasias in the occipital lobes. This malformation might affect the pattern of axonal projection to the posterior portion of the corpus callosum which is considered of crucial importance for the integration of crossed visuo-motor responses. From this paper the following conclusions can be drawn: a) epileptic patients with severe drug-resistant epilepsy due to bihemispheric cortical dysplasias are good candidates for callosotomy, b) one-stage extensive anterior callosotomy sparing the splenium is the procedure of choice, c) associated severe mental retardation seems to contra-indicate callosotomy, d) the neurophysiological study of the IHT can yield information on the functional status of the corpus callosum.

Interhemispheric integration of simple visuomotor responses in patients with partial callosal defects

Because of the organization of visual and motor pathways, simple manual responses to a light stimulus in the right or left visual hemifields are performed faster with uncrossed hand-field combinations than with crossed hand-field combinations. Uncrossed responses can be integrated within a single hemisphere, whereas crossed responses require a time-consuming interhemispheric transfer via the corpus callosum which is reflected in the difference between crossed and uncrossed reaction times. We investigated crossed-uncrossed differences (CUDs) in speed of simple visuomotor responses to lateralized flashes in seven subjects with an anterior section of the corpus callosum sparing the splenium and in one subject with an agenetic absence of the splenium due to a cerebrovascular malformation. There was no evidence of an abnormal prolongation of the CUDs in any of these subjects, in sharp contrast with the very long CUDs exhibited by an epileptic subject with a complete callosal section and two subjects with total callosal agenesis tested in the same experimental situation [1]. The normality of the CUDs in the subjects with partial callosal defects was not due to a postoperatory reorganization of interhemispheric communication, since there was no indication of an increased CUD in a patient tested as early as 5 days after the anterior callosotomy. These results are compatible with the assumption that both anterior and posterior callosal routes may subserve the integration of speeded manual responses to a visual stimulus directed to the hemisphere ipsilateral to the responding hand.

Left-right asymmetry of callosal transfer in normal human subjects

Interhemispheric transfer (IT) of visuomotor information can be assessed by measuring the crossed-uncrossed difference (CUD) in the Poffenberger paradigm [14]. We report a series of experiments aimed at casting light on two aspects of IT: the importance of motor response variables and the nature of the left-right asymmetries found in a recent meta-analysis of studies using the Poffenberger paradigm [10]. In Experiments 1 and 2 we found no effect of varying the finger used for response while there was a larger CUD when using the left hand in comparison to the right hand. In Experiment 3, which employed visual stimuli different from the two preceding experiments, CUD asymmetries were related to hemifields rather than to hands with a CUD larger for the right than for the left visual hemifield. These findings suggests that both motor and visual variables are important for CUD asymmetries to occur and are in keeping with a horse race model according to which overall speed of IT is determined by whichever signal (visual or pre-motor) is more rapid in crossing from one side to the other. As to the issue of lateral asymmetries in the CUD, the results of Expt. 3 have also shown that asymmetries arise only in tasks requiring an IT and therefore cannot depend upon additive hemispheric effects.

Effects of flunitrazepam on responses to lateralized visual stimuli: evidence for cerebral asymmetry of execution of manual movements to targets in contralateral and ipsilateral visual space

In order to examine the effects of benzodiazepines on response execution by the left and right hemisphere, flunitrazepam (1 mg) or placebo was administered to healthy, right handed volunteers in two separate experiments. In experiment 1, drug was administered daily during a treatment period of 8 days, and subjects were instructed to fixate vision centrally and to execute laterally directed manual responses corresponding to the position of visual stimuli presented in either the right or left hemifield. Experiment 2 was performed with a single dose and cross-over design, and subjects responded to the laterally presented visual stimuli by key press of a centrally positioned response device, i. e. neither detection of position of the stimulus in space nor response selection was required before initiation of the response. In experiment 1, intake of flunitrazepam generally increased reaction time more during response execution by the left as compared to the right hemisphere, and the most pronounced effect was observed on responses with the right hand, directed across the body axis, to visual stimuli presented in the left visual field. In contrast to these observations, in experiment 2, flunitrazepam impaired responses with the right and left hand practically to the same extent. Together, the results indicate that benzodiazepines may affect manual responses executed by left and right hemisphere differently, and that this asymmetry may be related to a stimulus-response compatibility effect in tasks that require response selection.

Estimation of interhemispheric dynamics from simple unimanual reaction time to extrafoveal stimuli

This essay reviews research on interhemispheric transfer time derived from simple unimanual reaction time to hemitachistoscopically presented visual stimuli. Part 1 reviews major theoretical themes including (a) the significance of the eccentricity effect on interhemispheric transfer time in the context of proposed underlying neurohistological constraints; (b) the significance of gender differences in interhemispheric transfer time and findings in dyslexics and left-handers in the context of a fetal brain testosterone model; and (c) the significance of complexity effects on interhemispheric transfer time in a context of "dynamic" vs. "hard-wired" concepts of the underlying interhemispheric communication systems. Part 2 consists of a meta-analysis of 49 published behavioral experiments, in view of drawing a portrait of the best set of experimental conditions apt to produce salient, reliable, and statistically significant measures of interhemispheric transfer time, namely (a) index rather than thumb response, (b) low rather than high target luminance, (c) short rather than prolonged target display, and (d) very eccentric rather than near-foveal stimulus location. Part 3 proposes a theoretical model of interhemispheric transfer time, postulating the measurable existence of fast and slow interhemispheric channels. The proposed mechanism's evolutionary adaptive value, the neurophysiological evidence in its support, and favorable functional evidence from studies of callosotomized patients are then presented followed by proposals for critical experimental tests of the model.

Is interhemispheric transfer of visuomotor information asymmetric? Evidence from a meta-analysis

Using a meta-analytic procedure we have analysed 16 studies employing a simple unimanual reaction time (RT) paradigm and lateralized visual stimuli to provide an estimate of interhemispheric transfer time in normal right-handed subjects. We found a significant overall RT advantage of the left visual field over the right and of the right hand over the left. These asymmetries can be explained by a superiority of the right hemisphere for the detection of simple visual stimuli and by a corresponding superiority of the left hemisphere for the execution of the manual response, respectively. Alternatively, they may be interpreted as related to an asymmetry of interhemispheric transmission of visuomotor information, with transfer from the right hemisphere (side of stimulus entry) to the left (side of response generation) faster than in the reverse direction. Although a direct test of these hypotheses is still lacking, we think that the evidence available is more in keeping with the latter possibility.