Normative Values for Intertrial Variability of Motor Responses to Nerve Root and Transcranial Stimulation: A Condition for Follow-Up Studies in Individual Subjects

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.

Multicentre assessment of motor and sensory evoked potentials in multiple sclerosis: reliability and implications for clinical trials

Background

Motor and sensory evoked potentials (EP) are potential candidate biomarkers for clinical trials in multiple sclerosis.

Objective

To determine test -retest reliability of motor EP (MEP) and sensory EP (SEP) and associated EP-scores in patients with multiple sclerosis.

Methods

In three centres, 16 relapsing and five progressive multiple sclerosis patients had MEPs and SEPs 1-29 days apart. Five neurophysiologists independently marked latencies by central reading. By variance component analysis, we estimated the critical difference (absolute reliability) for cross-sectional group comparison, comparison of longitudinal group changes, within-subject minimal detectable change and defined within-subject improvement.

Results

Cortical SEP responses and cortico-muscular MEP latencies were more reliable than central conduction times. For comparison of 20 subjects per arm, cross-sectional group difference ranged from 0.7 to 3.9 ms and 1.1 to 1.7, group difference in longitudinal changes from 0.4 to 1.8 ms and 0.36 to 0.62, within-subject minimal detectable change from 1.2 to 5.8 ms and 1.2 to 2.0, within-subject improvement from 0.8 to 3.8ms and 0.8 to 1.3, for single EP modalities and EP scores, respectively.

Conclusions

Multicentre EP assessment with central EP reading is feasible and reliable. The critical difference is reasonably low to detect significant group changes and to define responders. The results support the concept of using EP and EP-scores as candidate response biomarkers for quantification of disease progression and for studying remyelination in multiple sclerosis.

Preservation of motor maps with increased motor evoked potential amplitude threshold in RMT determination

OBJECTIVE

Non-invasive pre-surgical mapping of eloquent brain areas with navigated transcranial magnetic stimulation (nTMS) is a useful technique linked to the improvement of surgical planning and patient outcomes. The stimulator output intensity and subsequent resting motor threshold determination (rMT) are based on the motor-evoked potential (MEP) elicited in the target muscle with an amplitude above a predetermined threshold of 50 μV. However, a subset of patients is unable to achieve complete relaxation in the target muscles, resulting in false positives that jeopardize mapping validity with conventional MEP determination protocols. Our aim is to explore the feasibility and reproducibility of a novel mapping approach that investigates how an increase of the MEP amplitude threshold to 300 and 500 μV affects subsequent motor maps.

MATERIALS AND METHODS

Seven healthy subjects underwent motor mapping with nTMS. RMT was calculated with the conventional methodology in conjunction with experimental 300- and 500-μV MEP amplitude thresholds. Motor mapping was performed with 105% of rMT stimulator intensity using the FDI as the target muscle.

RESULTS

Motor mapping was possible in all patients with both the conventional and experimental setups. Motor area maps with a conventional 50-μV threshold showed poor correlation with 300-μV (α = 0.446, p < 0.001) maps, but showed excellent consistency with 500-μV motor area maps (α = 0.974, p < 0.001). MEP latencies were significantly less variable (23 ms for 50 μV vs. 23.7 ms for 300 μV vs. 23.7 ms for 500 μV, p < 0.001). A slight but significant increase of the electric field (EF) value was found (EF: 60.8 V/m vs. 64.8 V/m vs. 66 V/m p < 0.001).

CONCLUSION

Our study demonstrates the feasibility of increasing the MEP detection threshold to 500 μV in rMT determination and motor area mapping with nTMS without losing precision.

Intra and inter-session reliability of rapid Transcranial Magnetic Stimulation stimulus-response curves of tibialis anterior muscle in healthy older adults

OBJECTIVE

The clinical use of Transcranial Magnetic Stimulation (TMS) as a technique to assess corticospinal excitability is limited by the time for data acquisition and the measurement variability. This study aimed at evaluating the reliability of Stimulus-Response (SR) curves acquired with a recently proposed rapid protocol on tibialis anterior muscle of healthy older adults.

METHODS

Twenty-four neurologically-intact adults (age:55-75 years) were recruited for this test-retest study. During each session, six SR curves, 3 at rest and 3 during isometric muscle contractions at 5% of maximum voluntary contraction (MVC), were acquired. Motor Evoked Potentials (MEPs) were normalized to the maximum peripherally evoked response; the coil position and orientation were monitored with an optical tracking system. Intra- and inter-session reliability of motor threshold (MT), area under the curve (AURC), MEPmax, stimulation intensity at which the MEP is mid-way between MEPmax and MEPmin (I50), slope in I50, MEP latency, and silent period (SP) were assessed in terms of Standard Error of Measurement (SEM), relative SEM, Minimum Detectable Change (MDC), and Intraclass Correlation Coefficient (ICC).

RESULTS

The relative SEM was ≤10% for MT, I50, latency and SP both at rest and 5%MVC, while it ranged between 11% and 37% for AURC, MEPmax, and slope. MDC values were overall quite large; e.g., MT required a change of 12%MSO at rest and 10%MSO at 5%MVC to be considered a real change. Inter-sessions ICC were >0.6 for all measures but slope at rest and MEPmax and latency at 5%MVC.

CONCLUSIONS

Measures derived from SR curves acquired in <4 minutes are affected by similar measurement errors to those found with long-lasting protocols, suggesting that the rapid method is at least as reliable as the traditional methods. As specifically designed to include older adults, this study provides normative data for future studies involving older neurological patients (e.g. stroke survivors).

Reliability and minimal detectable change of transcranial magnetic stimulation outcomes in healthy adults: A systematic review

BACKGROUND

Transcranial magnetic stimulation (TMS) is used worldwide for noninvasively testing human motor systems but its psychometric properties remain unclear.

OBJECTIVE/HYPOTHESIS

This work systematically reviewed studies on the reliability of TMS outcome measures of primary motor cortex (M1) excitability in healthy humans, with an emphasis on retrieving minimal detectable changes (MDC).

METHODS

The literature search was performed in three databases (Pubmed, CINAHL, Embase) up to June 2016 and additional studies were identified through hand-searching. French and English-written studies had to report the reliability of at least one TMS outcome of M1 in healthy humans. Two independent raters assessed the eligibility of potential studies, and eligible articles were reviewed using a structured data extraction form and two critical appraisal scales.

RESULTS

A total of 34 articles met the selection criteria, which tested the intra- and inter-rater reliability (relative and absolute subtypes) of several TMS outcomes. However, our critical appraisal of studies raised concerns on the applicability and generalization of results because of methodological and statistical pitfalls. Importantly, MDC were generally large and likely affected by various factors, especially time elapsed between sessions and number of stimuli delivered.

CONCLUSIONS

This systematic review underlined that the evidence about the reliability of TMS outcomes is scarce and affected by several methodological and statistical problems. Data and knowledge of the review provided however relevant insights on the ability of TMS outcomes to track plastic changes within an individual or within a group, and recommendations were made to level up the quality of future work in the field.