Properties of low-threshold motor axons in the human median nerve

Neurophysiological and imaging biomarkers of lower motor neuron dysfunction in motor neuron diseases/amyotrophic lateral sclerosis: IFCN handbook chapter

This chapter discusses comprehensive neurophysiological biomarkers utilised in motor neuron disease (MND) and, in particular, its commonest form, amyotrophic lateral sclerosis (ALS). These encompass the conventional techniques including nerve conduction studies (NCS), needle and high-density surface electromyography (EMG) and H-reflex studies as well as novel techniques. In the last two decades, new methods of assessing the loss of motor units in a muscle have been developed, that are more convenient than earlier methods of motor unit number estimation (MUNE),and may use either electrical stimulation (e.g. MScanFit MUNE) or voluntary activation (MUNIX). Electrical impedance myography (EIM) is another novel approach for the evaluation that relies upon the application and measurement of high-frequency, low-intensity electrical current. Nerve excitability techniques (NET) also provide insights into the function of an axon and reflect the changes in resting membrane potential, ion channel dysfunction and the structural integrity of the axon and myelin sheath. Furthermore, imaging ultrasound techniques as well as magnetic resonance imaging are capable of detecting the constituents of morphological changes in the nerve and muscle. The chapter provides a critical description of the ability of each technique to provide neurophysiological insight into the complex pathophysiology of MND/ALS. However, it is important to recognise the strengths and limitations of each approach in order to clarify utility. These neurophysiological biomarkers have demonstrated reliability, specificity and provide additional information to validate and assess lower motor neuron dysfunction. Their use has expanded the knowledge about MND/ALS and enhanced our understanding of the relationship between motor units, axons, reflexes and other neural circuits in relation to clinical features of patients with MND/ALS at different stages of the disease. Taken together, the ultimate goal is to aid early diagnosis, distinguish potential disease mimics, monitor and stage disease progression, quantify response to treatment and develop potential therapeutic interventions.

Axonal excitability as an early biomarker of nerve involvement in hereditary transthyretin amyloidosis

OBJECTIVES

The treatment of hereditary transthyretin amyloidosis polyneuropathy (ATTRv-PN) has been revolutionised by genetic therapies, with dramatic improvements in patient outcomes. Whilst the optimal timing of treatment initiation remains unknown, early treatment is desirable. Consequently, the aim of the study was to develop biomarkers of early nerve dysfunction in ATTRv-PN.

METHODS

Ulnar motor and sensory axonal excitability studies were prospectively undertaken on 22 patients with pathogenic hereditary transthyretin amyloid (ATTRv) gene variants, 12 with large fibre neuropathy (LF+) and 10 without (LF-), with results compared to age- and sex-matched healthy controls.

RESULTS

In motor axons we identified a continuum of change from healthy controls, to LF- and LF+ ATTRv with progressive reduction in hyperpolarising threshold electrotonus (TEh40(10-20 ms): p = 0.04, TEh40(20-40 ms): p = 0.01 and TEh40(90-10 ms): p = 0.01), suggestive of membrane depolarisation. In sensory axons lower levels of subexcitability were observed on single (SubEx) and double pulse (SubEx2) recovery cycle testing in LF+ (SubEx: p = 0.015, SubEx2: p = 0.015, RC(2-1): p = 0.04) suggesting reduced nodal slow potassium conductance, which promotes sensory hyperexcitability, paraesthesia and pain. There were no differences in sensory or motor excitability parameters when comparing different ATTRv variants.

CONCLUSIONS

These progressive changes seen across the disease spectrum in ATTRv-PN suggest that axonal excitability has utility to identify early and progressive nerve dysfunction in ATTRv, regardless of genotype.

SIGNIFICANCE

Axonal excitability is a promising early biomarker of nerve dysfunction in ATTRv-PN.

Influence of transcutaneous electrical nerve stimulation on the distance walked by older adults during the 6-min test of walking endurance

The purpose of our study was to compare the influence of two types of transcutaneous electrical nerve stimulation (TENS) on the performance of older adults on the 6-min test of walking endurance and on the ability to maintain balance during upright standing. Twenty-six healthy older adults (72 ± 5.4 yrs) performed tests of motor function while TENS was applied to the tibialis anterior and rectus femoris muscles of each leg. Linear mixed models were used to compare the influence of TENS on walking distance in a 6-min test of walking endurance and on sway-area rate in tests of standing balance. There was a significant decrease in the distances walked in each minute of the 6-min walk test for both the Continuous and Burst TENS modes compared with Baseline (p < 0.01 and p < 0.001, respectively). The influence of TENS on walking distance was associated with several significant effects on the mean and coefficient of variation for stride length and stride frequency between the first and last minute of the test and between the two TENS modes and the Baseline values. In contrast, there was no significant effect of TENS on sway-area rate in any balance test, which indicates that the supplementary sensory feedback compromised walking performance of older adults but not the ability to maintain balance during upright standing.

Influence of transcutaneous electrical nerve stimulation on walking kinematics and standing balance of older adults who differ in walking speed

The purpose was to determine the impact of transcutaneous electrical nerve stimulation (TENS) on measures of walking kinematics and standing balance of healthy older adults who were stratified into two groups based on differences in the distance walked during the 6-min test of walking endurance. Regression models were developed to explain the variance in the 6-min distance and to assess the predictive power of balance metrics to categorize the 26 older adults (72 ± 5.4 yrs) as either slow or fast walkers. Walking kinematics were measured during 6- and 2-min walk tests that were performed with and without the concurrent application of TENS to the hip flexor and ankle dorsiflexor muscles. Participants walked briskly during the 6-min test and at a preferred pace during the 2-min test. The supplementary sensory stimulation provided by TENS did not alter the power of the models to explain the variance in the Baseline 6-min distance: Baseline, R² = 0.85; TENS, R² = 0.83. In contrast, TENS improved the explanatory power of the data obtained during the 2-min walk to account for the variance in the Baseline 6-min distance: no TENS, R² = 0.40; TENS, R² = 0.64. Logistic regression models based on force-plate and kinematic data obtained during the balance tasks were able to discriminate between the two groups with excellent certainty. The impact of TENS was greatest when older adults walked at a preferred speed but not when they walked at a brisk pace or performed tests of standing balance.

The effect of the subthreshold oscillation induced by the neurons' resonance upon the electrical stimulation-dependent instability

Repetitive electrical nerve stimulation can induce a long-lasting perturbation of the axon's membrane potential, resulting in unstable stimulus-response relationships. Despite being observed in electrophysiology, the precise mechanism underlying electrical stimulation-dependent (ES-dependent) instability is still an open question. This study proposes a model to reveal a facet of this problem: how threshold fluctuation affects electrical nerve stimulations. This study proposes a new method based on a Circuit-Probability theory (C-P theory) to reveal the interlinkages between the subthreshold oscillation induced by neurons' resonance and ES-dependent instability of neural response. Supported by in-vivo studies, this new model predicts several key characteristics of ES-dependent instability and proposes a stimulation method to minimize the instability. This model provides a powerful tool to improve our understanding of the interaction between the external electric field and the complexity of the biophysical characteristics of axons.

The test–retest reliability of large and small fiber nerve excitability testing with threshold tracking

Objective

Standard nerve excitability testing (NET) predominantly assesses Aα- and Aβ-fiber function, but a method examining small afferents would be of great interest in pain studies. Here, we examined the properties of a novel perception threshold tracking (PTT) method that preferentially activates Aδ-fibers using weak currents delivered by a novel multipin electrode and compared its reliability with NET.

Methods

Eighteen healthy subjects (mean age:34.06 ± 2.0) were examined three times with motor and sensory NET and PTT in morning and afternoon sessions on the same day (intra-day reliability) and after a week (inter-day reliability). NET was performed on the median nerve, while PTT stimuli were delivered through a multipin electrode located on the forearm. During PTT, subjects indicated stimulus perception via a button press and the intensity of the current was automatically increased or decreased accordingly by Qtrac software. This allowed changes in the perception threshold to be tracked during strength-duration time constant (SDTC) and threshold electrotonus protocols.

Results

The coefficient of variation (CoV) and interclass coefficient of variation (ICC) showed good-excellent reliability for most NET parameters. PTT showed poor reliability for both SDTC and threshold electrotonus parameters. There was a significant correlation between large (sensory NET) and small (PTT) fiber SDTC when all sessions were pooled (r = 0.29, p = 0.03).

Conclusions

Threshold tracking technique can be applied directly to small fibers via a psychophysical readout, but with the current technique, the reliability is poor.

Significance

Further studies are needed to examine whether Aβ-fiber SDTC may be a surrogate biomarker for peripheral nociceptive signalling.

Effects of 10-kHz Subthreshold Stimulation on Human Peripheral Nerve Activation

OBJECTIVE

The mechanisms of action of high-frequency stimulation (HFS) are unknown. We investigated the possible mechanism of subthreshold superexcitability of HFS on the excitability of the peripheral nerve.

MATERIALS AND METHODS

The ulnar nerve was stimulated at the wrist in six healthy participants with a single (control) stimulus, and the responses were compared with the responses to a continuous train of 5 seconds at frequencies of 500 Hz, 2.5 kHz, 5 kHz, and 10 kHz. Threshold intensity for compound muscle action potential (CMAP) was defined as intensity producing a 100-μV amplitude in ten sequential trials and "subthreshold" as 10% below the CMAP threshold. HFS threshold was defined as stimulation intensity eliciting visible tetanic contraction.

RESULTS

Comparing the threshold of single pulse stimulation for eliciting CMAP vs threshold for HFS response and pooling data at different frequencies (500 Hz-10 kHz) revealed a significant difference (p = 0.00015). This difference was most obvious at 10 kHz, with a mean value for threshold reduction of 42.2%.

CONCLUSIONS

HFS with a stimulation intensity below the threshold for a single pulse induces axonal superexcitability if applied in a train. It can activate the peripheral nerve and produce a tetanic muscle response. Subthreshold superexcitability may allow new insights into the mechanism of HFS.

Impact of stimulus duration on motor unit thresholds and alternation in compound muscle action potential scans

OBJECTIVE

To investigate the impact of stimulus duration on motor unit (MU) thresholds and alternation within compound muscle action potential (CMAP) scans.

METHODS

The stimulus duration (0.1, 0.2, 0.6, and 1.0 ms) in thenar CMAP scans and individual MUs of 14 healthy subjects was systematically varied. We quantified variability of individual MU's thresholds by relative spread (RS), MU thresholds by stimulus currents required to elicit target CMAPs of 5% (S5), 50% (S50) and 95% (S95) of the maximum CMAP, and relative range (RR) by 100*[S95-S5]/S50. We further assessed the strength-duration time constant (SDTC). Experimental observations were subsequently simulated to quantify alternation.

RESULTS

RS, unaffected by stimulus duration, was 1.65% averaged over all recordings. RR increased for longer stimulus duration (11.4% per ms, p < 0.001). SDTC shortened with higher target CMAPs (0.007 ms per 10% CMAP, p < 0.001). Experiments and simulations supported that this may underlie the increased RR. A short compared to long stimulus duration recruited relative more MUs at S50 (more alternation) than at the tails (less alternation).

CONCLUSIONS

The stimulus duration significantly affects MU threshold distribution and alternation within CMAP scans.

SIGNIFICANCE

Stimulation settings can be further optimized and their standardization is preferred when using CMAP scans for monitoring neuromuscular diseases.

Human adipose-derived mesenchymal stem cell-conditioned medium ameliorates polyneuropathy and foot ulceration in diabetic BKS db/db mice

BACKGROUND

Diabetic polyneuropathy (DPN) is the most common and early developing complication of diabetes mellitus, and the key contributor for foot ulcers development, with no specific therapies available. Different studies have shown that mesenchymal stem cell (MSC) administration is able to ameliorate DPN; however, limited cell survival and safety reasons hinder its transfer from bench to bedside. MSCs secrete a broad range of antioxidant, neuroprotective, angiogenic, and immunomodulatory factors (known as conditioned medium), which are all decreased in the peripheral nerves of diabetic patients. Furthermore, the abundance of these factors can be boosted in vitro by incubating MSCs with a preconditioning stimulus, enhancing their therapeutic efficacy. We hypothesize that systemic administration of conditioned medium derived from preconditioned MSCs could reverse DPN and prevent foot ulcer formation in a mouse model of type II diabetes mellitus.

METHODS

Diabetic BKS db/db mice were treated with systemic administration of conditioned medium derived from preconditioned human MSCs; conditioned medium derived from non-preconditioned MSCs or vehicle after behavioral signs of DPN was already present. Conditioned medium or vehicle administration was repeated every 2 weeks for a total of four administrations, and several functional and structural parameters characteristic of DPN were evaluated. Finally, a wound was made in the dorsal surface of both feet, and the kinetics of wound closure, re-epithelialization, angiogenesis, and cell proliferation were evaluated.

RESULTS

Our molecular, electrophysiological, and histological analysis demonstrated that the administration of conditioned medium derived from non-preconditioned MSCs or from preconditioned MSCs to diabetic BKS db/db mice strongly reverts the established DPN, improving thermal and mechanical sensitivity, restoring intraepidermal nerve fiber density, reducing neuron and Schwann cell apoptosis, improving angiogenesis, and reducing chronic inflammation of peripheral nerves. Furthermore, DPN reversion induced by conditioned medium administration enhances the wound healing process by accelerating wound closure, improving the re-epithelialization of the injured skin and increasing blood vessels in the wound bed in a skin injury model that mimics a foot ulcer.

CONCLUSIONS

Studies conducted indicate that MSC-conditioned medium administration could be a novel cell-free therapeutic approach to reverse the initial stages of DPN, avoiding the risk of lower limb amputation triggered by foot ulcer formation and accelerating the wound healing process in case it occurs.

Using strength-duration analysis to identify the afferent limb of the lateral spread response in hemifacial spasm patients during microvascular decompression surgery

Strength-duration analysis has been used to identify excitability differences between motor and sensory axons in human peripheral mixed nerves. The trigeminal and facial nerves have both been suggested to play a role in mediating the lateral spread response (LSR) in patients with hemifacial spasm (HFS). We sought to investigate this hypothesis by analyzing strength-duration properties of spasm side mentalis M wave and o. oculi LSR in 22 patients undergoing microvascular decompression surgery for HFS. Simultaneous recordings of mentalis M wave and o. oculi LSR prior to dural opening were collected following marginal mandibular facial nerve branch stimulation. Threshold responses were observed at stimulus pulse widths from 0.05 to 1.0 ms and the chronaxie and rheobase calculated from charge versus stimulus pulse width plots. The mean chronaxie (±SEM) of mentalis M wave was 0.34 ± 0.03 ms and 0.33 ± 0.04 ms for the LSR (p = 0.42, one-tailed t-test). The rheobase for the M wave (8.0 ± 1.0 mA) was found to be significantly different than the LSR rheobase (5.7 ± 0.7 mA; p = 0.03, one-tailed t-test) likely due to differences in the threshold amplitudes of the M wave versus the LSR. These results are highly suggestive of the facial nerve and not the trigeminal nerve in mediating the LSR.

Measurement of axonal excitability: Consensus guidelines

Measurement of axonal excitability provides an in vivo indication of the properties of the nerve membrane and of the ion channels expressed on these axons. Axonal excitability techniques have been utilised to investigate the pathophysiological mechanisms underlying neurological diseases. This document presents guidelines derived for such studies, based on a consensus of international experts, and highlights the potential difficulties when interpreting abnormalities in diseased axons. The present manuscript provides a state-of-the-art review of the findings of axonal excitability studies and their interpretation, in addition to suggesting guidelines for the optimal performance of excitability studies.

From Perception Threshold to Ion Channels-A Computational Study

Small-surface-area electrodes have successfully been used to preferentially activate cutaneous nociceptors, unlike conventional large area-electrodes, which preferentially activate large non-nociceptor fibers. Assessments of the strength-duration relationship, threshold electrotonus, and slowly increasing pulse forms have displayed different perception thresholds between large and small surface electrodes, which may indicate different excitability properties of the activated cutaneous nerves. In this study, the origin of the differences in perception thresholds between the two electrodes was investigated. It was hypothesized that different perception thresholds could be explained by the varying distributions of voltage-gated ion channels and by morphological differences between peripheral nerve endings of small and large fibers. A two-part computational model was developed to study activation of peripheral nerve fibers by different cutaneous electrodes. The first part of the model was a finite-element model, which calculated the extracellular field delivered by the cutaneous electrodes. The second part of the model was a detailed multicompartment model of an Aδ-axon as well as an Aβ-axon. The axon models included a wide range of voltage-gated ion channels: Na_TTXs, Na_TTXr, Na_p, K_dr, K_M, K_A, and HCN channel. The computational model reproduced the experimentally assessed perception thresholds for the three protocols, the strength-duration relationship, the threshold electrotonus, and the slowly increasing pulse forms. The results support the hypothesis that voltage-gated ion channel distributions and morphology differences between small and large fibers were sufficient to explain the difference in perception thresholds between the two electrodes. In conclusion, assessments of perception thresholds using the three protocols may be an indirect measurement of the membrane excitability, and computational models may have the possibility to link voltage-gated ion channel activation to perception threshold measurements.

Early motor resonance differentiates schizophrenia patients from healthy subjects and predicts social cognition performance

BACKGROUND

Diminished motor resonance (facilitation of motor potentials during action observation) is possibly related to social cognition deficits in schizophrenia. Adequate social cognition requires the successful moment-to-moment appraisal of social stimuli over a temporal window. However, similar changes in motor resonance with successive action observation stimuli are unknown. We compared the time-course of motor resonance evoked during successive action observation stimuli between schizophrenia patients (antipsychotic-naïve and medicated) and healthy subjects and examined its association with social cognition performance.

METHOD

Fifty-four schizophrenia patients (33 antipsychotic-naive) and 45 healthy subjects underwent 10-recordings (T1 to T10) of cortical reactivity, using two single (sp)- and two paired-pulse (pp) transcranial magnetic stimulation (TMS) paradigms, while they observed goal-directed actions and a static image. They also underwent comprehensive social cognition assessments.

RESULTS

Sp-motor resonance revealed a significant quadratic time effect (initial fall and then rise) in patients and healthy subjects [F=12.21, P=0.001]. Such a pattern was not observed for pp-motor resonance. We categorized motor resonance as early (T1-T3), middle (T4-T7) and late (T8-T10) based on pair-wise comparisons. Early, but not middle or late sp-motor resonance was reduced in antipsychotic naïve patients compared to the medicated patients and healthy subjects (F=3.41, P=0.037). Social cognition composite score had significant correlations with both early sp-motor resonance (r=0.34, P=0.01) and early pp-motor resonance (r=0.314, P=0.02) in the combined patient group.

CONCLUSIONS

Motor resonance time-courses did not vary across groups. The magnitude of early motor resonance was reduced in the antipsychotic-naïve schizophrenia group, compared to healthy subjects. Early phase motor resonance was associated with social cognition deficits in patients.

Upper and lower limb motor axons demonstrate differential excitability and accommodation to strong hyperpolarizing currents during induced hyperthermia

Length-dependent peripheral neuropathy typically involves the insidious onset of sensory loss in the lower limbs before later progressing proximally. Recent evidence proposes hyperpolarization-activated cyclic nucleotide-gated (HCN) channels as dysfunctional in rodent models of peripheral neuropathy, and therefore differential expression of HCN channels in the lower limbs was hypothesized as a pathophysiological mechanism accounting for the pattern of symptomatology within this study. We studied six healthy participants, using motor axon excitability including strong and long [-70% and -100% hyperpolarizing threshold electrotonus (TEh)] hyperpolarizing currents to preferably study HCN channel function from the median and tibial nerves from high (40%) and low (20%) threshold. This was recorded at normothermia (~32°C) and then repeated during hyperthermia (~40°C) as an artificial hyperpolarizing axon stress. Significant differences between recovery cycle, superexcitability, accommodation to small depolarizing currents, and alterations in late stages of the inward-rectifying currents of strongest (-70% and -100% TEh) currents were observed in the lower limbs during hyperthermia. We demonstrate differences in late I_H current flow, which implies higher expression of HCN channel isoforms. The findings also indicate their potential inference in the symptomatology of length-dependent peripheral neuropathies and may be a unique target for minimizing symptomatology and pathogenesis in acquired disease. NEW & NOTEWORTHY This study demonstrates nerve excitability differences between the upper and lower limbs during hyperthermia, an experimentally induced axonal stress. The findings indicate that there is differential expression of slow hyperpolarization-activated cyclic nucleotide-gated (HCN) channel isoforms between the upper and lower limbs, which was demonstrated through strong, long hyperpolarizing currents during hyperthermia. Such mechanisms may underlie postural control but render the lower limbs susceptible to dysfunction in disease states.

In vivo evidence for reduced ion channel expression in motor axons of patients with amyotrophic lateral sclerosis

KEY POINTS

The progressive loss of motor units in amyotrophic lateral sclerosis (ALS) is initially compensated for by the reinnervation of denervated muscle fibres by surviving motor axons. A disruption in protein homeostasis is thought to play a critical role in the pathogenesis of ALS. The changes in surviving motor neurons were studied by comparing the nerve excitability properties of moderately and severely affected single motor axons from patients with ALS with those from single motor axons in control subjects. A mathematical model indicated that approximately 99% of the differences between the ALS and control units could be explained by a non-selective reduction in the expression of all ion channels. These changes in ALS patients are best explained by a failure in the supply of ion channel and other membrane proteins from the diseased motor neuron.

ABSTRACT

Amyotrophic lateral sclerosis (ALS) is characterised by a progressive loss of motor units and the reinnervation of denervated muscle fibres by surviving motor axons. This reinnervation preserves muscle function until symptom onset, when some 60-80% of motor units have been lost. We have studied the changes in surviving motor neurons by comparing the nerve excitability properties of 31 single motor axons from patients with ALS with those from 21 single motor axons in control subjects. ALS motor axons were classified as coming from moderately or severely affected muscles according to the compound muscle action potential amplitude of the parent muscle. Compared with control units, thresholds were increased, and there was reduced inward and outward rectification and greater superexcitability following a conditioning impulse. These abnormalities were greater in axons from severely affected muscles, and were correlated with loss of fine motor skills. A mathematical model indicated that 99.1% of the differences between the moderately affected ALS and control units could be explained by a reduction in the expression of all ion channels. For the severely affected units, modelling required, in addition, an increase in the current leak through and under the myelin sheath. This might be expected if the anchoring proteins responsible for the paranodal seal were reduced. We conclude that changes in axonal excitability identified in ALS patients are best explained by a failure in the supply of ion channel and other membrane proteins from the diseased motor neuron, a conclusion consistent with recent animal and in vitro human data.

Characterization of diabetic neuropathy progression in a mouse model of type 2 diabetes mellitus

Diabetes mellitus (DM) is one of most common chronic diseases with an increasing incidence in most countries. Diabetic neuropathy (DN) is one of the earliest and main complications of diabetic patients, which is characterized by progressive, distal-to-proximal degeneration of peripheral nerves. The cellular and molecular mechanisms that trigger DN are highly complex, heterogeneous and not completely known. Animal models have constituted a valuable tool for understanding diabetes pathophysiology; however, the temporal course of DN progression in animal models of type 2 diabetes (T2DM) is not completely understood. In this work, we characterized the onset and progression of DN in BKS diabetic (db/db) mice, including the main functional and histological features observed in the human disease. We demonstrated that diabetic animals display progressive sensory loss and electrophysiological impairments in the early-to-mid phases of the disease. Furthermore, we detected an early decrease in intraepidermal nerve fiber (IENF) density in 18-week-old diabetic mice, which is highly associated with sensory loss and constitutes a reliable marker of DN. Other common histological parameters of DN – like Schwann cells apoptosis and infiltration of CD3⁺ cells in the sciatic nerve – were altered in mid-to-late phases of the disease. Our results support the general consensus that DN evolves from initial functional to late structural changes. This work aimed to characterize the progression of DN in a reliable animal model sharing the main human disease features, which is necessary to assess new therapies for this complex disease. Finally, we also aimed to identify an effective temporal window where these potential treatments could be successfully applied.

Summary: We characterized the main functional and structural diabetic neuropathy features during early-to-late phases of type 2 diabetes mellitus. This study aimed to identify a therapeutic window for new treatments.

Hyperpolarization-activated cyclic-nucleotide-gated channels potentially modulate axonal excitability at different thresholds

Hyperpolarization-activated cyclic-nucleotide-gated (HCN) channels mediate differences in sensory and motor axonal excitability at different thresholds in animal models. Importantly, HCN channels are responsible for voltage-gated inward rectifying (I_h) currents activated during hyperpolarization. The I_h currents exert a crucial role in determining the resting membrane potential and have been implicated in a variety of neurological disorders, including neuropathic pain. In humans, differences in biophysical properties of motor and sensory axons at different thresholds remain to be elucidated and could provide crucial pathophysiological insights in peripheral neurological diseases. Consequently, the aim of this study was to characterize sensory and motor axonal function at different threshold. Median nerve motor and sensory axonal excitability studies were undertaken in 15 healthy subjects (45 studies in total). Tracking targets were set to 20, 40, and 60% of maximum for sensory and motor axons. Hyperpolarizing threshold electrotonus (TEh) at 90-100 ms was significantly increased in lower threshold sensory axons times (F = 11.195, P < 0.001). In motor axons, the hyperpolarizing current/threshold (I/V) gradient was significantly increased in lower threshold axons (F = 3.191, P < 0.05). The minimum I/V gradient was increased in lower threshold motor and sensory axons. In conclusion, variation in the kinetics of HCN isoforms could account for the findings in motor and sensory axons. Importantly, assessing the function of HCN channels in sensory and motor axons of different thresholds may provide insights into the pathophysiological processes underlying peripheral neurological diseases in humans, particularly focusing on the role of HCN channels with the potential of identifying novel treatment targets.NEW & NOTEWORTHY Hyperpolarization-activated cyclic-nucleotide-gated (HCN) channels, which underlie inward rectifying currents (I_h), appear to mediate differences in sensory and motor axonal properties. Inward rectifying currents are increased in lower threshold motor and sensory axons, although different HCN channel isoforms appear to underlie these changes. While faster activating HCN channels seem to underlie I_h changes in sensory axons, slower activating HCN isoforms appear to be mediating the differences in I_h conductances in motor axons of different thresholds. The differences in HCN gating properties could explain the predilection for dysfunction of sensory and motor axons in specific neurological diseases.

Excitability and firing behavior of single slow motor axons transmitting natural repetitive firing of human motoneurons

Excitability of motor axons is critically important for realizing their main function, i.e., transmitting motoneuron firing to muscle fibers. The present study was designed to explore excitability recovery and firing behavior in single slow axons transmitting human motoneuron firing during voluntary muscle contractions. The abductor digiti minimi, flexor carpi ulnaris, and tibialis anterior were investigated during threshold stimulation of corresponding motor nerves. Motor unit (MU) firing index in response to testing volleys evoking M-responses was used as a physiological measure of axonal excitability and its changes throughout a target interspike interval (ISI) were explored. It was shown that axons displayed an early irresponsive period (within the first ~2-5 ms of a target ISI) that was followed by a responsive period (for the next 5-17 ms of the ISI), in which MUs fired axonal doublets, and a later irresponsive period. At the beginning of the responsive period, M-responses showed small latency delays. However, since at that ISI moment, MUs displayed excitability recovery with high firing index, slight latency changes may be considered as a functionally insignificant phenomenon. The duration of axonal doublet ISIs did not depend on motoneuron firing frequencies (range 4.3-14.6 imp/s). The question of whether or not traditionally described axonal recovery excitability cycle is realistic in natural motor control is discussed. In conclusion, the present approach, exploring, for the first time, excitability recovery in single slow axons during motoneuron natural activation, can provide further insight into axonal firing behavior in normal states and diseases.NEW & NOTEWORTHY Excitability of single slow axons was estimated by motor unit firing index in response to motor nerve stimulation, and its changes throughout a target interspike interval were explored during transmitting human motoneuron natural firing. It was found that axons exhibited early irresponsive, responsive, and later irresponsive periods. Findings question whether the traditionally described axonal excitability recovery cycle is realistic in natural motor control.

Modification of multiple ion channel functions in vivo by pharmacological inhibition: observation by threshold tracking and modeling

Maintenance of axonal excitability relies on complex balance by multiple ion currents, but its evaluation is limited by in vitro single channel neurophysiological study on overall behavior. We sought to evaluate behaviors of multiple ion currents by pharmacological blockade. The threshold tracking technique was used to measure multiple excitability indices on tail sensory nerve of normal male mice before and after administration of either BaCl₂ or ivabradine. Mathematical modeling was used to identify the interval changes of the channel parameters. After administration of BaCl₂ and ivabradine, the following changes were present: greater threshold changes of both depolarizing and hyperpolarizing threshold electrotonus by both; additionally, reduced S2 accommodation, reduced late subexcitability and increased superexcitability by BaCl₂, increased S3 accommodation by ivabradine. Mathematical modelling implied reduction of slow K⁺ conductance, along with reduction of H conductance (Ih) by BaCl₂; and reduction of Ih while augmentation of K⁺ conductances by ivabradine. Pharmacological blockade of a selective ion channel may be compensated by other ion channels. Unintended effects by ion channel modification could be caused by secondary current alteration by multiple ion channels. J. Med. Invest. 64: 30-38, February, 2017.

The Ih Channel Gene Promotes Synaptic Transmission and Coordinated Movement in Drosophila melanogaster

Hyperpolarization-activated cyclic nucleotide-gated “HCN” channels, which underlie the hyperpolarization-activated current (I_h), have been proposed to play diverse roles in neurons. The presynaptic HCN channel is thought to both promote and inhibit neurotransmitter release from synapses, depending upon its interactions with other presynaptic ion channels. In larvae of Drosophila melanogaster, inhibition of the presynaptic HCN channel by the drug ZD7288 reduces the enhancement of neurotransmitter release at motor terminals by serotonin but this drug has no effect on basal neurotransmitter release, implying that the channel does not contribute to firing under basal conditions. Here, we show that genetic disruption of the sole HCN gene (Ih) reduces the amplitude of the evoked response at the neuromuscular junction (NMJ) of third instar larvae by decreasing the number of released vesicles. The anatomy of the (NMJ) is not notably affected by disruption of the Ih gene. We propose that the presynaptic HCN channel is active under basal conditions and promotes neurotransmission at larval motor terminals. Finally, we demonstrate that Ih partial loss-of-function mutant adult flies have impaired locomotion, and, thus, we hypothesize that the presynaptic HCN channel at the (NMJ) may contribute to coordinated movement.

Integrative action of axonal membrane explored by trains of subthreshold stimuli applied to the peripheral nerve

OBJECTIVE

The objective of this study was to provide evidence on the integrative action of axonal membrane in humans and its ability to integrate multipulse subthreshold stimuli and generate action potential.

METHODS

The median nerve was stimulated at the wrist in six healthy subjects and 17 patients who underwent low spine surgery by means of percutaneous electrodes, with trains of one to nine near-threshold constant-current stimuli of 500-μs duration. The interstimulus interval between stimuli was 2 or 4 ms. The compound muscle action potential (CMAP) was recorded from the abductor pollicis brevis muscle using subcutaneous needle electrodes in patients and surface electrodes in healthy subjects. Total intravenous anesthesia (TIVA) without a muscle relaxant was used in all patients, and measurements were performed at the end of surgery.

RESULT

A single near-threshold stimulus did not generate CMAP either in the healthy subjects or in the patients. However, when the number of near-threshold stimuli was increased to two to nine stimuli, and packed into a short train with interstimulus intervals of 2 or 4 ms, a CMAP of varying amplitude from 100 to 200 μV was successfully elicited.

CONCLUSION

We concluded that the described phenomenon might be explained by the integrative action of the axonal membrane, which is able to summate the trains of subthreshold stimuli, increasing the resting potential to the firing level, and consequently generating CMAP. This is because the subthreshold stimuli make the axonal membrane hyperexcitable.

SIGNIFICANCE

This phenomenon is not very well explored in clinical neurophysiology, and it needs to be studied further. This can explain some neurophysiologic phenomena during intraoperative monitoring.

Is the human mirror neuron system plastic? Evidence from a transcranial magnetic stimulation study

Virtual lesions in the mirror neuron network using inhibitory low-frequency (1Hz) transcranial magnetic stimulation (TMS) have been employed to understand its spatio-functional properties. However, no studies have examined the influence of neuro-enhancement by using excitatory high-frequency (20Hz) repetitive transcranial magnetic stimulation (HF-rTMS) on these networks. We used three forms of TMS stimulation (HF-rTMS, single and paired pulse) to investigate whether the mirror neuron system facilitates the motor system during goal-directed action observation relative to inanimate motion (motor resonance), a marker of putative mirror neuron activity. 31 healthy individuals were randomized to receive single-sessions of true or sham HF-rTMS delivered to the left inferior frontal gyrus - a component of the human mirror system. Motor resonance was assessed before and after HF-rTMS using three TMS cortical reactivity paradigms: (a) 120% of resting motor threshold (RMT), (b) stimulus intensity set to evoke motor evoked potential of 1-millivolt amplitude (SI1mV) and (c) a short latency paired pulse paradigm. Two-way RMANOVA showed a significant group (true versus sham) X occasion (pre- and post-HF-rTMS motor resonance) interaction effect for SI1mV [F(df)=6.26 (1, 29), p=0.018] and 120% RMT stimuli [F(df)=7.01 (1, 29), p=0.013] indicating greater enhancement of motor resonance in the true HF-rTMS group than the sham-group. This suggests that HF-rTMS could adaptively modulate properties of the mirror neuron system. This neuro-enhancement effect is a preliminary step that can open translational avenues for novel brain stimulation therapeutics targeting social-cognition deficits in schizophrenia and autism.

Mirror neuron dysfunction and ego-boundary disturbances in schizophrenia: a transcranial magnetic stimulation study

BACKGROUND

Ego-boundary disturbance (EBD) is a unique symptom cluster characterized by passivity experiences (involving thoughts, actions, emotions and sensations) attributed by patients to some external agency. The neurobiology of these "first rank" symptoms is poorly understood. Aberrant mirror neuron activation may explain impaired self-monitoring and agency attribution underlying these symptoms. We aim to study mirror neuron activity (MNA) in schizophrenia patients with and without EBD using transcranial magnetic stimulation (TMS).

MATERIALS AND METHODS

50 right-handed schizophrenia patients (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) were evaluated using the Mini-International Neuropsychiatric Interview and the Positive and Negative Syndrome Scale. They completed a TMS experiment to assess putative premotor MNA. Motor evoked potential (MEP) was recorded in the right first dorsal interosseous muscle (FDI) with (a) 120% of resting motor threshold (RMT), (b) stimulus intensity set to evoke MEP of motor threshold 1 mV amplitude (MT1), (c) two paired pulse paradigms (short- and long interval intra-cortical inhibition). These were done in three states: Actual observation of an action using the FDI, virtual-observation (video) of this action and resting state. The percent change of MEP from resting to action-observation states formed the measure of putative MNA.

RESULTS

MNA measured using MT1 and 120% RMT paradigms was significantly lower in the 18 patients with EBD (thought-broadcast/withdrawal/insertion, made-act/impulse/affect and somatic passivity) than the 32 patients without EBD (t = 2.431, P = 0.020; t = 2.051, P = 0.04 respectively for the two paradigms). The two groups did not differ on age, gender, education and total symptom scores.

CONCLUSION

Schizophrenia patients with EBD have lower premotor MNA. This highlights the role of MNA dysfunction in the pathophysiology of this unique and intriguing symptom cluster in schizophrenia.

IH activity is increased in populations of slow versus fast motor axons of the rat

Much is known about the electrophysiological variation in motoneuron somata across different motor units. However, comparatively less is known about electrophysiological variation in motor axons and how this could impact function or electrodiagnosis in healthy or diseased states. We performed nerve excitability testing on two groups of motor axons in Sprague–Dawley rats that are known to differ significantly in their chronic daily activity patterns and in the relative proportion of motor unit types: one group innervating the soleus (“slow motor axons”) and the other group innervating the tibialis anterior (“fast motor axons”) muscles. We found that slow motor axons have significantly larger accommodation compared to fast motor axons upon application of a 100 ms hyperpolarizing conditioning stimulus that is 40% of axon threshold (Z = 3.24, p = 0.001) or 20% of axon threshold (Z = 2.67, p = 0.008). Slow motor axons had larger accommodation to hyperpolarizing currents in the current-threshold measurement (-80% Z = 3.07, p = 0.002; -90% Z = 2.98, p = 0.003). In addition, we found that slow motor axons have a significantly smaller rheobase than fast motor axons (Z = -1.99, p = 0.047) accompanied by a lower threshold in stimulus-response curves. The results provide evidence that slow motor axons have greater activity of the hyperpolarization-activated inwardly rectifying cation conductance (I_H) than fast motor axons. It is possible that this difference between fast and slow axons is caused by an adaptation to their chronic differences in daily activity patterns, and that this adaptation might have a functional effect on the motor unit. Moreover, these findings indicate that slow and fast motor axons may react differently to pathological conditions.

Reduced mirror neuron activity in schizophrenia and its association with theory of mind deficits: evidence from a transcranial magnetic stimulation study

BACKGROUND

The "mirror-neuron system" has been proposed to be a neurophysiological substrate for social cognition (SC) ability. We used transcranial magnetic stimulation (TMS) paradigms to compare putative mirror neuron activity (MNA) in 3 groups: antipsychotic-naive, medicated schizophrenia patients, and healthy comparison subjects. We also explored the association between MNA and SC ability in patients.

METHODS

Fifty-four consenting right-handed schizophrenia patients (33 antipsychotic naive) and 45 matched healthy comparison subjects completed a TMS experiment to assess putative premotor MNA. We used 4 TMS paradigms of eliciting motor-evoked potentials (MEP) in the right first dorsal interosseous (FDI) muscle. These were applied while the subjects observed a goal-directed action involving the FDI (actual action and its video) and a static image. The difference in the amplitude of the MEP while they observed the static image and the action provided a measure of MNA. Subjects also underwent SC assessments (theory of mind [ToM], emotion processing, and social perception).

RESULTS

Two-way repeated measures ANOVA revealed significant group × occasion interaction effect in 3 TMS paradigms, indicating deficient motor facilitation during action observation relative to rest state in antipsychotic-naive schizophrenia patients as compared with the other two groups. Among patients, there were significant direct correlations between measures of MNA and ToM performance.

CONCLUSIONS

Antipsychotic-naive schizophrenia patients have poorer MNA than medicated patients and healthy controls. Measures of putative MNA had significant and consistent associations with ToM abilities. These findings suggest a possibility of deficient mirror neuron system underlying SC deficits in schizophrenia.

Axonal excitability in X-linked dominant Charcot Marie Tooth disease

OBJECTIVE

We investigated peripheral nerve function in X-linked Charcot-Marie-Tooth disease type 1 (CMTX1), and considered the functional consequences of mutant connexin-32.

METHODS

Twelve subjects (9 female, 3 male) were assessed clinically, by nerve conduction and excitability studies. A model of myelinated axon was used to clarify the contributing changes.

RESULTS

All subjects had abnormal nerve conduction. Excitability studies on median nerve axons showed greater threshold changes to hyperpolarising currents, with "fanning out" in threshold electrotonus, and modest changes in the recovery cycle. Modelling suggested shortening of internodal length, increase in nodal fast potassium currents, shift of the voltage activation hyperpolarisation-activated cyclic-nucleotide-gated channels, and axonal hyperpolarisation. Plotting threshold versus extent of hyperpolarising threshold change in threshold electrotonus distinguished the CMTX1 patients from other chronic demyelinating neuropathies reported in the literature except hereditary neuropathy with pressure palsies (HNPP).

CONCLUSIONS

Some measures of axonal excitability are similar in CMTX1 and HNPP (though not the recovery cycle), but they differ from those in other chronic demyelinating neuropathies. The findings in CMTX1 are consistent with known pathology, but are not correlated to neuropathy severity.

SIGNIFICANCE

The findings in CMTX1 could be largely the result of morphological alterations, rather than plasticity in channel expression or distribution.

Increased variability of axonal excitability in amyotrophic lateral sclerosis

OBJECTIVE

Amyotrophic lateral sclerosis (ALS) is characterised by the increased excitability of motoneurons and heterogeneous loss of axons. The heterogeneous nature of the disease process among fibres may show variability of excitability in ALS.

METHODS

Multiple nerve excitability tests were performed in 28 ALS patients and 23 control subjects, by tracking at the varying threshold levels (10%, 20%, 40% and 60% of maximum amplitudes).

RESULTS

In normal controls, excitability measures at low target levels have the following characteristics compared to those at high target levels: longer strength-duration time constant, greater threshold reduction during depolarising currents and smaller threshold increase to hyperpolarising currents. ALS patients had less clear amplitude dependency of the parameters than the controls, indicating variability of axonal excitability. Three ALS patients demonstrated greater target-amplitude-dependent threshold changes in threshold electrotonus than controls, suggesting selective axonal hyperexcitability.

CONCLUSIONS

Some of the ALS patients had variable axonal excitability at different target amplitudes, suggesting preferential hyperexcitability in the axons with low target amplitude levels.

SIGNIFICANCE

Variable membrane potentials of motor axons in ALS may be assessed by recording excitability testing at different target amplitude levels.

The voltage dependence of I(h) in human myelinated axons

HCN channels are responsible for I(h), a voltage-gated inwardly rectifying current activated by hyperpolarization. This current appears to be more active in human sensory axons than motor and may play a role in the determination of threshold. Differences in I(h) are likely to be responsible for the high variability in accommodation to hyperpolarization seen in different subjects. The aim of this study was to characterise this current in human axons, both motor and sensory. Recordings of multiple axonal excitability properties were performed in 10 subjects, with a focus on the changes in threshold evoked by longer and stronger hyperpolarizing currents than normally studied. The findings confirm that accommodation to hyperpolarization is greater in sensory than motor axons in all subjects, but the variability between subjects was greater than the modality difference. An existing model of motor axons was modified to take into account the behaviour seen with longer and stronger hyperpolarization, and a mathematical model of human sensory axons was developed based on the data collected. The differences in behaviour of sensory and motor axons and the differences between different subjects are best explained by modulation of the voltage dependence, along with a modest increase of expression of the underlying conductance of I(h). Accommodation to hyperpolarization for the mean sensory data is fitted well with a value of -94.2 mV for the mid-point of activation (V(0.5)) of I(h) as compared to -107.3 mV for the mean motor data. The variation in response to hyperpolarization between subjects is accounted for by varying this parameter for each modality (sensory: -89.2 to -104.2 mV; motor -87.3 to -127.3 mV). These voltage differences are within the range that has been described for physiological modulation of I(h) function. The presence of slowly activated I(h) isoforms on both motor and sensory axons was suggested by modelling a large internodal leak current and a masking of the Na(+)/K(+)-ATPase pump activity by a tonic depolarization. In addition to an increased activation of I(h), the modelling suggests that in sensory axons the nodal slow K(+) conductance is reduced, with consequent depolarization of resting membrane potential, and action potential of shorter duration.

[Increased variability of membrane potentials in amyotrophic lateral sclerosis]

Amyotrophic lateral sclerosis (ALS) is characterized by increased excitability of motor neurons and early involvement of large motor fibers that have low electrical thresholds. Despite the advent of new techniques of threshold tracking, exploration of this abnormal excitability has not been straightforward, by tracking at the single target level as previous reported, because of the heterogeneous nature of the disease process among fibers that have variable thresholds. We have assessed different populations of motor axons by tracking at four different target response levels (10, 20, 40 and 60% of maximum compound muscle action potentials), and conducted multiple nerve excitability tests in 27 ALS patients and 23 control subjects. In normal controls, axons with low thresholds have the following characteristics compared to those with high thresholds: greater threshold reduction during depolarizing currents and smaller threshold increase to hyperpolarizing currents, reflecting the order of the fiber size. In contrast, ALS patients lacked these relationships, suggesting increased variability of axonal membrane potentials. Three ALS patients demonstrated changes in threshold electrotonus, consistent with overt membrane depolarization, as seen in ischemic nerves. The variability of motor nerve excitability accounts for fasciculations, confirms previously reported dysfunction of potassium channels, and suggests failure of Na(+)/K(+)pumps, possibly caused by mitochondrial dysfunctions at the early stage.

Dose effects of oxaliplatin on persistent and transient Na+ conductances and the development of neurotoxicity

Background

Oxaliplatin, a platinum-based chemotherapy utilised in the treatment of colorectal cancer, produces two forms of neurotoxicity- acute sensorimotor neuropathic symptoms and a dose-limiting chronic sensory neuropathy. Given that a Na⁺ channelopathy has been proposed as the mechanism underlying acute oxaliplatin-induced neuropathy, the present study aimed to determine specific mechanisms of Na⁺ channel dysfunction.

Methodology/Principal Findings

Specifically the function of transient and persistent Na⁺ currents were followed during treatment and were investigated in relation to oxaliplatin dose level. Eighteen patients were assessed before and after a single oxaliplatin infusion with motor and sensory axonal excitability studies performed on the median nerve at the wrist. While refractoriness (associated with Na⁺ channel inactivation) was significantly altered post-oxaliplatin infusion in both motor (Pre: 31.7±6.4%; Post: 68.8±14.5%; P≤.001) and sensory axons (Pre: 31.4±5.4%; Post: 21.4±5.5%; P<.05), strength-duration time constant (marker of persistent Na⁺ conductances) was not significantly altered post-infusion (Motor Pre: 0.395±0.01 ms; Post: 0.394±0.02 ms; NS; Sensory Pre:0.544±0.03 ms; Post: 0.535±0.05 ms; NS). However, changes in strength-duration time constant were significantly correlated with changes in refractoriness in motor and sensory axons (Motor correlation coefficient = −.65; P<.05; Sensory correlation coefficient = .67; P<.05).

Conclusions/Significance

It is concluded that the predominant effect of acute oxaliplatin exposure in human motor and sensory axons is mediated through changes in transient rather than persistent Na⁺ conductances. These findings are likely to have implications for the design and trial of neuroprotective strategies.