Assessment of corticospinal excitability after traumatic spinal cord injury using MEP recruitment curves: a preliminary TMS study

Influence of sports on cortical excitability in patients with spinal cord injury: a TMS study

Background

Patients with spinal cord injury (SCI) show abnormal cortical excitability that might be caused by deafferentation. We hypothesize a reduced short-interval intracortical inhibition preceding movement in patients with SCI compared with healthy participants. In addition, we expect that neuroplasticity induced by different types of sports can modulate intracortical inhibition during movement preparation in patients with SCI.

Methods

We used a reaction test and paired-pulse transcranial magnetic stimulation to record cortical excitability, assessed by measuring amplitudes of motor-evoked potentials in preparation of movement. The participants were grouped as patients with SCI practicing wheelchair dancing (n = 7), other sports (n = 6), no sports (n = 9), and healthy controls (n = 24).

Results

There were neither significant differences between healthy participants and the patients nor between the different patient groups. A non-significant trend (p = .238), showed that patients engaged in sports have a stronger increase in cortical excitability compared with patients of the non-sportive group, while the patients in the other sports group expressed the highest increase in cortical excitability.

Conclusion

The small sample sizes limit the statistical power of the study, but the trending effect warrants further investigation of different sports on the neuroplasticity in patients with SCI. It is not clear how neuroplastic changes impact the sensorimotor output of the affected extremities in a patient. This needs to be followed up in further studies with a greater sample size.

Transcranial magnetic stimulation input-output curve slope differences suggest variation in recruitment across muscle representations in primary motor cortex

Measurement of the input-output (IO) curves of motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation (TMS) can be used to assess corticospinal excitability and motor recruitment. While IO curves have been used to study disease and pharmacology, few studies have compared the IO curves across the body. This study sought to characterize IO curve parameters across the dominant and non-dominant sides of upper and lower limbs in healthy participants. Laterality preferences were assessed in eight healthy participants and IO curves were measured bilaterally for the first dorsal interosseous (FDI), biceps brachii (BB), and tibialis anterior (TA) muscles. Results show that FDI has lower motor threshold than BB which is, in turn, lower than TA. In addition, both BB and TA have markedly shallower logarithmic IO curve slopes from small to large MEP responses than FDI. After normalizing these slopes by their midpoints to account for differences in motor thresholds, which could result from geometric factors such as the target depth, large differences in logarithmic slopes remain present between all three muscles. The differences in slopes between the muscles could not be explained by differences in normalized IO curve spreads, which relate to the extent of the cortical representation and were comparable across the muscles. The IO curve differences therefore suggest muscle-dependent variations in TMS-evoked recruitment across the primary motor cortex, which should be considered when utilizing TMS-evoked MEPs to study disease states and treatment effects.

Motor unit activity and synaptic inputs to motoneurons in the caudal part of the injured spinal cord

Spinal cord injury (SCI) disrupts neuronal function below the lesion epicenter, causing disuse muscle atrophy. We investigated motor unit (MU) activity and synaptic inputs to motoneurons in the caudal region of the injured spinal cord. Participants with C4-C7 cervical injuries were studied. The extensor digitorum communis (EDC) muscle, which is mainly innervated by C8, was assessed for disuse muscle atrophy. Using advanced electromyography and signal-processing techniques, we examined the concurrent activation of a substantial population of MUs during force-tracking tasks. We found that in participants with SCI (n = 9), both MU discharge rates and the amplitudes of MU action potentials were significantly lower than in controls (n = 9). After SCI, MUs were recruited in a limited force range as the strength of muscle contractions increased, implying a disruption in the orderly MU recruitment pattern. Coherence analysis revealed reduced synaptic inputs to motoneurons in the delta band (0.5-5 Hz) for participants with SCI, suggesting diminished common synaptic inputs to the EDC muscle. In addition, participants with SCI exhibited greater muscle force variability. Using principal component analysis on low-frequency MU discharge rates, we found that the first common component (FCC) captured the most discharge variability in participants with SCI. The coefficients of variation (CV) of the FCC correlated with force signal CVs, suggesting force variability mainly results from common synaptic inputs to the EDC muscle after SCI. These results advance our understanding of the neurophysiology of disuse muscle atrophy in human SCI, paving the way for therapeutic interventions to restore muscle function.NEW & NOTEWORTHY This study analyzed motor unit (MU) function below the lesion epicenter in patients with spinal cord injury (SCI). We found reduced MU discharge rates and action potential amplitudes in participants with SCI compared with controls. The strength of common synaptic inputs to motoneurons was reduced in patients with SCI, with increased force variability primarily due to low-frequency oscillations of common inputs. This study enhances understanding of neurophysiological and behavioral changes in disuse muscle atrophy post-SCI.

Single-cell transcriptomics reveals ependymal subtypes related to cytoskeleton dynamics as the core driver of syringomyelia pathological development

Syringomyelia is a common clinical lesion associated with cerebrospinal fluid flow abnormalities. By a reversible model with chronic extradural compression to mimic human canalicular syringomyelia, we explored the spatiotemporal pathological alterations during syrinx development. The most dynamic alterations were observed in ependymal cells (EPCs), oligodendrocyte lineage, and microglia, as a response to neuroinflammation. Among different cell types, EPC subtypes experienced obvious dynamic alterations, which were accompanied by ultrastructural changes involving the ependymal cytoskeleton, cilia, and dynamic injury in parenchyma primarily around the central canal, corresponding to the single-cell transcripts. After effective decompression, the syrinx resolved with the recovery of pathological damage and overall neurological function, implying that for syringomyelia in the early stage, there was still endogenous repair potential coexisting with immune microenvironment imbalance. Ependymal remodeling and cilia restoration might be important for better resolution of syringomyelia and parenchymal injury recovery.

Spinal Cord Injury and Loss of Cortical Inhibition

After spinal cord injury (SCI), the destruction of spinal parenchyma causes permanent deficits in motor functions, which correlates with the severity and location of the lesion. Despite being disconnected from their targets, most cortical motor neurons survive the acute phase of SCI, and these neurons can therefore be a resource for functional recovery, provided that they are properly reconnected and retuned to a physiological state. However, inappropriate re-integration of cortical neurons or aberrant activity of corticospinal networks may worsen the long-term outcomes of SCI. In this review, we revisit recent studies addressing the relation between cortical disinhibition and functional recovery after SCI. Evidence suggests that cortical disinhibition can be either beneficial or detrimental in a context-dependent manner. A careful examination of clinical data helps to resolve apparent paradoxes and explain the heterogeneity of treatment outcomes. Additionally, evidence gained from SCI animal models indicates probable mechanisms mediating cortical disinhibition. Understanding the mechanisms and dynamics of cortical disinhibition is a prerequisite to improve current interventions through targeted pharmacological and/or rehabilitative interventions following SCI.

Stimulation Parameters Used During Repetitive Transcranial Magnetic Stimulation for Motor Recovery and Corticospinal Excitability Modulation in SCI: A Scoping Review

There is a growing interest in non-invasive stimulation interventions as treatment strategies to improve functional outcomes and recovery after spinal cord injury (SCI). Repetitive transcranial magnetic stimulation (rTMS) is a neuromodulatory intervention which has the potential to reinforce the residual spinal and supraspinal pathways and induce plasticity. Recent reviews have highlighted the therapeutic potential and the beneficial effects of rTMS on motor function, spasticity, and corticospinal excitability modulation in SCI individuals. For this scoping review, we focus on the stimulation parameters used in 20 rTMS protocols. We extracted the rTMS parameters from 16 published rTMS studies involving SCI individuals and were able to infer preliminary associations between specific parameters and the effects observed. Future investigations will need to consider timing, intervention duration and dosage (in terms of number of sessions and number of pulses) that may depend on the stage, the level, and the severity of the injury. There is a need for more real vs. sham rTMS studies, reporting similar designs with sufficient information for replication, to achieve a significant level of evidence regarding the use of rTMS in SCI.

Temporal and spatial cellular and molecular pathological alterations with single-cell resolution in the adult spinal cord after injury

Spinal cord injury (SCI) involves diverse injury responses in different cell types in a temporally and spatially specific manner. Here, using single-cell transcriptomic analyses combined with classic anatomical, behavioral, electrophysiological analyses, we report, with single-cell resolution, temporal molecular and cellular changes in crush-injured adult mouse spinal cord. Data revealed pathological changes of 12 different major cell types, three of which infiltrated into the spinal cord at distinct times post-injury. We discovered novel microglia and astrocyte subtypes in the uninjured spinal cord, and their dynamic conversions into additional stage-specific subtypes/states. Most dynamic changes occur at 3-days post-injury and by day-14 the second wave of microglial activation emerged, accompanied with changes in various cell types including neurons, indicative of the second round of attacks. By day-38, major cell types are still substantially deviated from uninjured states, demonstrating prolonged alterations. This study provides a comprehensive mapping of cellular/molecular pathological changes along the temporal axis after SCI, which may facilitate the development of novel therapeutic strategies, including those targeting microglia.

Bone Marrow Mesenchymal Stem Cell-Derived Exosomes Accelerate Functional Recovery After Spinal Cord Injury by Promoting the Phagocytosis of Macrophages to Clean Myelin Debris

Macrophage phagocytosis contributes predominantly to processing central nervous system (CNS) debris and further facilitates neurological function restoration after CNS injury. The aims of this study were to evaluate the effect of bone marrow mesenchymal stem cells (BMSC)-derived exosomes (BMSC-Exos) on the phagocytic capability of macrophages to clear myelin debris and to investigate the underlying molecular mechanism during the spinal cord injury (SCI) process. This work reveals that monocyte-derived macrophages (MDMs) infiltrating into the SCI site could efficiently engulf myelin debris and process phagocytic material. However, the phagocytic ability of macrophages to clear tissue debris is compromised after SCI. The administration of BMSC-Exos as an approach for SCI treatment could rescue macrophage normal function by improving the phagocytic capability of myelin debris internalization, which is beneficial for SCI repair, as evidenced by better axon regrowth and increased hindlimb locomotor functional recovery in a rodent model. Examination of macrophage treatment with BMSC-Exos revealed that BMSC-Exos could promote the capacity of macrophages to phagocytose myelin debris in vitro and could create a regenerative microenvironment for axon regrowth. In addition, we confirmed that BMSC-Exo treatment resulted in improved phagocytosis of engulfed myelin debris by promoting the expression of macrophage receptor with collagenous structure (MARCO) in macrophages. The inhibition of MARCO with PolyG (a MARCO antagonist) impaired the effect of BMSC-Exos on the phagocytic capacity of macrophages and resulted in compromised myelin clearance at the lesion site, leading to further tissue damage and impaired functional healing after SCI. In conclusion, these data indicated that targeting the phagocytic ability of macrophages may have therapeutic potential for the improvement in functional healing after SCI. The administration of BMSC-Exos as a cell-free immune therapy strategy has wide application prospects for SCI treatment.

Neurophysiological Changes in the First Year After Cell Transplantation in Sub-acute Complete Paraplegia

Neurophysiological testing can provide quantitative information about motor, sensory, and autonomic system connectivity following spinal cord injury (SCI). The clinical examination may be insufficiently sensitive and specific to reveal evolving changes in neural circuits after severe injury. Neurophysiologic data may provide otherwise imperceptible circuit information that has rarely been acquired in biologics clinical trials in SCI. We reported a Phase 1 study of autologous purified Schwann cell suspension transplantation into the injury epicenter of participants with complete subacute thoracic SCI, observing no clinical improvements. Here, we report longitudinal electrophysiological assessments conducted during the trial. Six participants underwent neurophysiology screening pre-transplantation with three post-transplantation neurophysiological assessments, focused on the thoracoabdominal region and lower limbs, including MEPs, SSEPs, voluntarily triggered EMG, and changes in GSR. We found several notable signals not detectable by clinical exam. In all six participants, thoracoabdominal motor connectivity was detected below the clinically assigned neurological level defined by sensory preservation. Additionally, small voluntary activations of leg and foot muscles or positive lower extremity MEPs were detected in all participants. Voluntary EMG was most sensitive to detect leg motor function. The recorded MEP amplitudes and latencies indicated a more caudal thoracic level above which amplitude recovery over time was observed. In contrast, further below, amplitudes showed less improvement, and latencies were increased. Intercostal spasms observed with EMG may also indicate this thoracic “motor level.” Galvanic skin testing revealed autonomic dysfunction in the hands above the injury levels. As an open-label study, we can establish no clear link between these observations and cell transplantation. This neurophysiological characterization may be of value to detect therapeutic effects in future controlled studies.

A mouse model of complete-crush transection spinal cord injury made by two operations

Background

More and more studies have focused on the treatment of spinal cord injury (SCI) by tissue engineering, but there is still no ideal animal model that can genuinely and objectively simulate the real pathological process in clinical practice. Also, given the increasing availability and use of genetically modified animals in basic science research, it has become essential to develop clinically related models for SCI for use in mice.

Methods

Forty-eight C57BL/6 mice were divided into three groups (injured/sham/uninjured). We determined the scar range made by the first crush injury by specimen observation, hematoxylin and eosin (HE) staining, and immunofluorescence staining. Transection to completely remove a 2-mm spinal cord segment centered on the lesion core was completed 6 weeks after the first injury in injured groups, whereas the sham group only underwent re-exposure of the spinal cord without transection injury. The characteristics of this SCI model were fully ascertained by specimen observation, HE staining, immunofluorescence staining, and quantitative real-time polymerase chain reaction (qRT-PCR).

Results

No mice died after the first injury. Histopathological findings suggested a scar range of 2 mm. After the second operation, 2 mice of the injured group and 1 mouse of the sham group died. The Basso Mouse Scale (BMS) score and motor evoked potential (MEP) results showed that the neurological function of mice did not recover. Immunostaining showed that there were no neurons or neurofilament residues in the lesion core 4 weeks after the second injury. Astrocytes encapsulated immune cells to form dense glial scars. Most immune cells were confined to the core of the lesion and formed fibrous scars with the fibroblasts. At the same time, there was considerable angiogenesis in the lesion core and around the injury. The results of qRT-PCR showed that Ptprc was highly expressed in the lesion core, while Gfap, nestin, Cnp, and Sv2b were highly expressed in the adjacent region. This suggests that the lesion core is a highly inflammatory zone, but there may be spontaneous neurogenesis adjacent to the lesion core.

Conclusions

The mouse crash-complete transection SCI model made by the two operations has good simulation, high feasibility, and high reproducibility; it will be a useful tool for pre-clinical testing of SCI treatment.

Unbiased transcriptomic analyses reveal distinct effects of immune deficiency in CNS function with and without injury

The mammalian central nervous system (CNS) is considered an immune privileged system as it is separated from the periphery by the blood brain barrier (BBB). Yet, immune functions have been postulated to heavily influence the functional state of the CNS, especially after injury or during neurodegeneration. There is controversy regarding whether adaptive immune responses are beneficial or detrimental to CNS injury repair. In this study, we utilized immunocompromised SCID mice and subjected them to spinal cord injury (SCI). We analyzed motor function, electrophysiology, histochemistry, and performed unbiased RNA-sequencing. SCID mice displayed improved CNS functional recovery compared to WT mice after SCI. Weighted gene-coexpression network analysis (WGCNA) of spinal cord transcriptomes revealed that SCID mice had reduced expression of immune function-related genes and heightened expression of neural transmission-related genes after SCI, which was confirmed by immunohistochemical analysis and was consistent with better functional recovery. Transcriptomic analyses also indicated heightened expression of neurotransmission-related genes before injury in SCID mice, suggesting that a steady state of immune-deficiency potentially led to CNS hyper-connectivity. Consequently, SCID mice without injury demonstrated worse performance in Morris water maze test. Taken together, not only reduced inflammation after injury but also dampened steady-state immune function without injury heightened the neurotransmission program, resulting in better or worse behavioral outcomes respectively. This study revealed the intricate relationship between immune and nervous systems, raising the possibility for therapeutic manipulation of neural function via immune modulation.

Mobile Application for Adaptive Threshold Hunting in Transcranial Magnetic Stimulation

Application of transcranial magnetic stimulation (TMS) is expanding with many studies applying adaptive threshold hunting to determine a motor threshold (MT). In addition to being a measure of corticospinal excitability, the MT is used as a baseline stimulation intensity (SI) to which following investigative or modulatory SIs are referenced to. Currently available tools for determining MTs include system-integrated tools and third-party stand-alone software. System-integrated MT-tools are still rarely available and the stand-alone software usually demand a separate computer, and hence possess additional space-requirements. I introduce and validate a free Android-based mobile application ("ATH-tool") for adaptive threshold hunting of the MT. The objective is to allow for a simple and validated recording of MTs with sharing capabilities for logs. For comparison, I applied Motor Threshold Assessment Tool 2.0, to compare the MT-values determined with the new application, as it applies closely the same routine. Computational validation with known true threshold values confirmed that the new application captured the true MT at high precision (error ≤ 0.9%). Previously published data on motor evoked potentials (MEPs) were used to simulate realistic response occurrence by considering experimental data from 15 healthy subjects at different stimulation intensities. The MTs of the different methods agreed well (ICC ≥ 0.971, ). There was no significant difference between the MTs determined with the different methods ( p ≥ 0.151 ). The novel mobile application should make it easier for researchers and clinicians to determine MTs and log the results.

Current Change Rate Influences Sensorimotor Cortical Excitability During Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is frequently used in rehabilitation therapy to improve motor recovery. To optimize the stimulatory effect of NMES, the parameters of NMES, including stimulation mode, location, current intensity, and duration, among others have been investigated; however, these studies mainly focused on the effects of changing parameters in the current plateau stage of the NMES cycle, while the impacts on other stages, such as the current rising stage, have yet to be investigated. In this article, we studied the electroencephalograph (EEG) effects during NMES, with different rates of current change in the rising stage, and stable current intensity in the plateau stage. EEG signals (64-channel) were collected from 28 healthy subjects, who were administered with high, medium, or low current change rate (CCR) NMES through a right-hand wrist extensor. Time-frequency analysis and brain source analysis, using the LORETA method, were used to investigate neural activity in sensorimotor cortical areas. The strengths of cortical activity induced by different CCR conditions were compared. NMES with a high CCR activated the sensorimotor cortex, despite the NMES current intensity in the plateau stage lower than the motor threshold. Reduction of the Alpha 2 band (10–13 Hz) event related spectral power (ERSP) during NMES stimulation was significantly enhanced by increasing CCR (p < 0.05). LORETA-based source analysis demonstrated that, in addition to typical sensory areas, such as primary somatosensory cortex (S1), sensorimotor areas including primary motor cortex (M1), premotor cortex (PMC), and somatosensory association cortex (SAC) were all activated by within threshold NMES. Furthermore, compared with the low CCR condition, cortical activity was significantly enhanced in the S1, M1, and PMC areas under high CCR conditions. This study shows CCR in the NMES rising stage can affect EEG responses in the sensorimotor cortex and suggests that CCR is an important parameter applicable to the optimization of NMES treatment.

Cortical function and corticomotoneuronal adaptation in monomelic amyotrophy

OBJECTIVE

To evaluate corticomotoneuronal integrity in monomelic amyotrophy using threshold tracking transcranial magnetic stimulation (TT-TMS).

METHODS

Cortical excitability studies were prospectively performed in 8 monomelic amyotrophy patients and compared to 21 early-onset amyotrophic lateral sclerosis (ALS) patients and 40 healthy controls. Motor evoked potentials responses were recorded over abductor pollicis brevis.

RESULTS

Maximal motor evoked potential (MEP/CMAP ratio) was significantly increased in monomelic amyotrophy compared with controls (monomelic amyotrophy 51.2±12.4%; control 22.7±2.1%, p=0.04). Averaged short-interval intracortical inhibition (SICI, ISI 1-7ms) in monomelic amyotrophy patients was similar to controls (monomelic amyotrophy 9.6±2.1%; control 10.0±0.9%, p=0.98). However, it was significantly reduced in early-onset ALS in comparison with monomelic amyotrophy patients (monomelic amyotrophy 9.6±2.1%; ALS 2.3±1.7%, p<0.001). Averaged SICI is a good parameter (area under the curve 0.79, p=0.02) to discriminate between monomelic amyotrophy and early-onset ALS patients.

CONCLUSIONS

TT-TMS technique has identified normal cortical function in monomelic amyotrophy, a feature that distinguishes it from early-onset ALS. The greater corticomotoneuronal projections to spinal motoneurons may represent central nervous system adaptive change in monomelic amyotrophy.

SIGNIFICANCE

Corticomotoneuronal dysfunction does not drive the lower motor neurone loss presented in monomelic amyotrophy.

Bilateral Knee Extensor Fatigue Modulates Force and Responsiveness of the Corticospinal Pathway in the Non-fatigued, Dominant Elbow Flexors

Exercise-induced fatigue affects muscle performance and modulates corticospinal excitability in non-exercised muscles. The purpose of this study was to investigate the effect of bilateral knee extensor fatigue on dominant elbow flexor (EF) maximal voluntary force production and corticospinal excitability. Transcranial magnetic, transmastoid electrical and brachial plexus electrical stimulation (BPES) were used to investigate corticospinal, spinal, and muscle excitability of the dominant EF before and after a bilateral knee extensor fatiguing protocol or time matched rest period (control). For both sessions three stimuli were delivered every 1.5 s during the three pre-test time points and during the 1st, 3rd, 6th, 9th and 12th post-test 5 s EF isometric maximal voluntary contractions (MVC). In both conditions, overall, EF MVC force (p < 0.001) decreased progressively from repetition #1 to #12 during the post-test MVC protocol. EF MVC force (p < 0.001, ES = 0.9, Δ10.3%) decrements were more pronounced in the knee extensor fatigue intervention condition. In addition, there were no significant differences between conditions for biceps brachii electromyographic (EMG) activity (p = 0.43), motor evoked potentials (MEPs) amplitude (p = 0.908) or MEP silent period (SP; p = 0.776). However, the fatigue condition exhibited a lower MEP/cervicomedullary MEP (CMEP) ratio (p = 0.042, ES = 2.5, Δ25%) and a trend toward higher CMEP values (p = 0.08, ES = 0.5, Δ20.4%). These findings suggest that bilateral knee extensor fatigue can impair performance and modulate corticospinal excitability of the EF.