Non-invasive electrical and magnetic stimulation of the brain, spinal cord, roots and peripheral nerves: Basic principles and procedures for routine clinical and research application. An updated report from an I.F.C.N. Committee

These guidelines provide an up-date of previous IFCN report on “Non-invasive electrical and magnetic stimulation of the brain, spinal cord and roots: basic principles and procedures for routine clinical application” (Rossini et al., 1994). A new Committee, composed of international experts, some of whom were in the panel of the 1994 “Report”, was selected to produce a current state-of-the-art review of non-invasive stimulation both for clinical application and research in neuroscience.

Since 1994, the international scientific community has seen a rapid increase in non-invasive brain stimulation in studying cognition, brain–behavior relationship and pathophysiology of various neurologic and psychiatric disorders. New paradigms of stimulation and new techniques have been developed. Furthermore, a large number of studies and clinical trials have demonstrated potential therapeutic applications of non-invasive brain stimulation, especially for TMS. Recent guidelines can be found in the literature covering specific aspects of non-invasive brain stimulation, such as safety (Rossi et al., 2009), methodology (Groppa et al., 2012) and therapeutic applications (Lefaucheur et al., 2014).

This up-dated review covers theoretical, physiological and practical aspects of non-invasive stimulation of brain, spinal cord, nerve roots and peripheral nerves in the light of more updated knowledge, and include some recent extensions and developments.

Comparative host-coronavirus protein interaction networks reveal pan-viral disease mechanisms

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a grave threat to public health and the global economy. SARS-CoV-2 is closely related to the more lethal but less transmissible coronaviruses SARS-CoV-1 and Middle East respiratory syndrome coronavirus (MERS-CoV). Here, we have carried out comparative viral-human protein-protein interaction and viral protein localization analyses for all three viruses. Subsequent functional genetic screening identified host factors that functionally impinge on coronavirus proliferation, including Tom70, a mitochondrial chaperone protein that interacts with both SARS-CoV-1 and SARS-CoV-2 ORF9b, an interaction we structurally characterized using cryo-electron microscopy. Combining genetically validated host factors with both COVID-19 patient genetic data and medical billing records identified molecular mechanisms and potential drug treatments that merit further molecular and clinical study.

The responses of human muscle spindle endings to vibration of non-contracting muscles

1. In micro-electrode recordings from the human peroneal and tibial nerves, the responses of thirty-two primary spindle endings, thirteen secondary spindle endings and three Golgi tendon organs were studied during vibration of the tendons of the receptor-bearing muscles in the leg. The amplitude of the applied vibration was 1-5 mm and the frequency was varied from 20 to 220 Hz. As checked with e.m.g. and torque measurements, the muscles of the leg were relaxed during the sequences analysed. 2. Providing that the vibrator was accurately applied, all endings responded with discharges phase-locked to the vibration cycles, the discharge rates being at the vibration frequency or at subharmonics of that frequency. The response to vibration was of abrupt onset and offset, was maintained for the duration of vibration, and was not subject to fluctuation with changes in attention or with remote muscle contraction. 3. The maximal discharge rate that could be achieved varied from one ending to the next, and increased with the length of the receptor-bearing muscle. For endings driven at their maximal rate an increase in vibration frequency produced a decrease in discharge rates as the ending changed to a subharmonic pattern of response. The converse occurred on decreasing vibration frequency. 4. For any given muscle length, primary endings could generally be driven to higher rates than secondary endings but there was a wide range of responsiveness within each group and a significant overlap between the groups. At medium muscle length, the most responsive primary endings could be driven up to 220 Hz but secondary endings did not reach discharge rates higher than 100 Hz. 5. With combined vibration and passive movements, primary endings exhibited maximal vibration responsiveness during the stretching phases, sometimes firing twice per vibration cycle. During the shortening phases, however, they usually ceased responding to the vibratory stimulus. The vibration responsiveness of secondary endings was not potentiated to the same extent by on-going muscle stretch or reduced to the same extent by on-going muscle shortening. Thus, during shortening, secondary endings may be more responsive than primary endings. 6. The responses of primary endings to tendon taps were reduced during muscle vibration, a reduction which probably contributes to vibration-induced suppression of tendon jerks. Additionally, as the muscle shortened after tendon percussion, there was a transient pause in the response to vibration.

Threshold tracking techniques in the study of human peripheral nerve

Conventional electrophysiological tests of nerve function focus on the number of conducting fibers and their conduction velocity. These tests are sensitive to the integrity of the myelin sheath, but provide little information about the axonal membrane. Threshold tracking techniques, in contrast, test nerve excitability, which depends on the membrane properties of the axons at the site of stimulation. These methods are sensitive to membrane potential, and to changes in membrane potential caused by activation of ion channels and electrogenic ion pumps, including those under the myelin sheath. This review describes the range of threshold tracking techniques that have been developed for the study of human nerves in vivo: resting threshold is compared with the threshold altered by a change in environment (e.g., ischemia), by a preceding single impulse (e.g., refractoriness, superexcitability) or impulse train, or by a subthreshold current (e.g., threshold electrotonus). Few clinical studies have been reported so far, mainly in diabetic neuropathy and motor neuron disease. Threshold measurements seem well suited for studies of metabolic and toxic neuropathies but insensitive to demyelination. Until suitable equipment becomes more widely available, their full potential is unlikely to be realized.

Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy

One hundred thirty-eight consecutive, nonrandomized patients, with equivalent demographic and preoperative physiologic parameters, underwent either a video-assisted thoracic surgical (VATS) approach (n = 81) or a limited lateral thoracotomy (LLT) approach (n = 57) to accomplish pulmonary resection for peripheral lung lesions (< or = 3 cm in diameter). Wedge resection was done in 74 VATS patients and 19 LLT patients. Seven patients underwent VATS lobectomy and 38 patients had lobectomy performed through an LLT. Pain was quantitated by postoperative narcotic requirements, the need for intercostal/epidural analgesia, and patient perception of pain index scoring. Shoulder and pulmonary function (forced expiratory volume in 1 second) were measured preoperatively, 3 days postoperatively, and at 3 weeks of follow-up. Patients undergoing VATS experienced significantly less postoperative pain. No patients undergoing VATS required intercostal block/epidural analgesia; 31 LLT patients (54%) required this treatment for breakthrough pain (p = 0.001). Narcotic requirements were less (p = 0.05) among VATS patients, which correlated with lower perception of pain index after operation for VATS patients. Shoulder girdle strength was equally impaired at day 3, but function was more improved in VATS patients at 3 weeks (p = 0.01). Patients undergoing wedge resection alone by LLT had greater impairment in early (day 3) pulmonary function (forced expiratory volume in 1 second) (p = 0.002); this difference from VATS was not sustained at 3 weeks. Video-assisted thoracic surgery is associated with reduced pain, shoulder dysfunction, and early pulmonary impairment compared with LLT for select patients requiring pulmonary resection.

Multiple measures of axonal excitability: a new approach in clinical testing

From measurements of nerve excitability and the changes in excitability produced by nerve impulses and conditioning currents, it is possible to infer information about the membrane potential and biophysical properties of peripheral axons. Such information cannot be obtained from conventional nerve conduction studies. This article describes a new method that enables several such measurements to be made on a motor nerve quickly and reproducibly, with minimal operator intervention. The protocol measures stimulus-response behavior using two stimulus durations (from which the distribution of strength-duration time constants can be estimated), threshold electrotonus to 100-ms polarizing currents, a current-threshold relationship (indicating inward and outward rectification), and the recovery of excitability following supramaximal activation. The method was tested on 30 healthy volunteers, stimulating the median nerve at the wrist and recording from the abductor pollicis brevis. The results were comparable with previously published normal data, but the recordings took less than 10 min. The convenience and brevity of the new method make it appropriate for routine clinical use.

The responses of human muscle spindle endings to vibration during isometric contraction

1. An human subjects, vibration of amplitude 1-5 mm and frequency 20-220 Hz was applied to the tendons of muscles in the leg to examine the effects on the discharge of primary and secondary endings during manoeuvres designed to alter the level of fusimotor drive. 2. In four experiments, the peroneal nerve was completely blocked with lidocaine proximal to the recording site in order to de-efferent spindle endings temporarily. The responses to muscle stretch and vibration, as seen in multi-unit recordings and in single unit recordings, were similar during the block as in the relaxed state prior to the block. Thus, these experiments provided no evidence for a functionally effective resting fusimotor drive. 3. The responses to vibration of nine primary endings and four secondary endings were examined during isometric voluntary contractions of the receptor-bearing muscles. Providing that the endings were responding submaximally in the relaxed state, voluntary contraction enhanced the response to vibration, suggesting co-activation of the fusimotor system sufficient to compensate for mechanical unloading. Unloading effects were observed during contractions of neighbouring synergistic muscles, indicating a close spatial relationship between the co-activated skeletomotor and fusimotor outflows. 4. Recordings were obtained from ten primary endings and seven secondary endings during isometric reflex contractions resulting from the vibratory stimulus (TVR contractions). For twelve endings, the appearance of the tonic vibration reflex in the receptor-bearing muscle resulted in a significant decrease in the response to vibration, suggesting that the endings were unloaded by the extrafusal contraction. On voluntary suppression of the reflex contraction spindle responses reverted to their previous levels. 5. These results suggest that the tonic vibration reflex, like the tendon jerk reflex, operates predominantly or exclusively on alpha motoneurones and that it does not utilize the same cortically originating efferent pathways as are used in the performance of voluntary contractions.

Excitability of human axons

The excitability of human axons can be studied reliably using the technique of threshold tracking, which allows the strength of a test stimulus to be adjusted by computer to activate a defined fraction of the maximal nerve or muscle action potential. The stimulus current that just evokes the target response is considered the "threshold" for that response. More useful than the resting threshold are other indices of axonal excitability derived from pairs of threshold measurements, such as refractoriness, supernormality, strength-duration time constant and "threshold electrotonus" (i.e. the changes in threshold produced by long-lasting depolarizing or hyperpolarizing current pulses). Each of these measurements depends on membrane potential and on other biophysical properties of the axons. Together they can provide new information about the pathophysiology underlying abnormalities in excitability in neuropathy.

In vivo skeletal responses to porous-surfaced implants subjected to small induced motions

Cylindrical porous-coated implants were placed in the distal femoral metaphyses of twenty dogs and were subjected to zero, twenty, forty, or 150 micrometers of oscillatory motion for eight hours each day for six weeks with use of a specially designed loading apparatus. The in vivo skeletal responses to the different magnitudes of relative motion were evaluated. Histological analysis demonstrated growth of bone into the porous coatings of all of the implants, including those that had been subjected to 150 micrometers of motion. However, the ingrown bone was in continuity with the surrounding bone only in the groups of implants that had not been subjected to motion or that had been subjected to twenty micrometers of motion; in contrast, the implants that had been subjected to forty micrometers of motion were surrounded in part by trabecular bone but also in part by fibrocartilage and fibrous tissue, and those that had been subjected to 150 micrometers of motion were surrounded by dense fibrous tissue. Trabecular microfractures were identified around three of the five implants that had been subjected to forty micrometers of motion and around four of the five that had been subjected to 150 micrometers of motion, suggesting that the ingrown bone had failed at the interface because of the large movements. The architecture of the surrounding trabecular bone also was altered by the micromotion of the implant. The implants that had stable ingrowth of bone were surrounded by a zone of trabecular atrophy, whereas those that had unstable ingrowth of bone were surrounded by a zone of trabecular hypertrophy. The trabeculae surrounding the fibrocartilage or fibrous tissue that had formed around the implants that had been subjected to forty or 150 micrometers of motion had been organized into a shell of dense bone tangential to the implant (that is, a neocortex outside the non-osseous tissue).

A structural biology community assessment of AlphaFold2 applications

Most proteins fold into 3D structures that determine how they function and orchestrate the biological processes of the cell. Recent developments in computational methods for protein structure predictions have reached the accuracy of experimentally determined models. Although this has been independently verified, the implementation of these methods across structural-biology applications remains to be tested. Here, we evaluate the use of AlphaFold2 (AF2) predictions in the study of characteristic structural elements; the impact of missense variants; function and ligand binding site predictions; modeling of interactions; and modeling of experimental structural data. For 11 proteomes, an average of 25% additional residues can be confidently modeled when compared with homology modeling, identifying structural features rarely seen in the Protein Data Bank. AF2-based predictions of protein disorder and complexes surpass dedicated tools, and AF2 models can be used across diverse applications equally well compared with experimentally determined structures, when the confidence metrics are critically considered. In summary, we find that these advances are likely to have a transformative impact in structural biology and broader life-science research.

Monosynaptic and oligosynaptic contributions to human ankle jerk and H-reflex

Studies were undertaken in normal subjects to determine whether it is possible for oligosynaptic reflex pathways to affect motoneuron discharge in the ankle jerk and H-reflex of the soleus. It is argued that if the rising phase of the increase in excitability of the soleus motoneuron pool produced by tendon percussion or by electrical stimulation of the peripheral nerve lasts more than a few milliseconds and if the increase in excitability takes several milliseconds to reach the threshold for motoneuron discharge, these reflexes are unlikely to be exclusively monosynaptic. In relaxed subjects, changes in excitability of the soleus motoneuron pool produced by tendon percussion and by electrical stimulation of the tibial nerve were examined using conditioning stimuli just below threshold and a test H-reflex just above threshold for a reflex response. The increase in excitability due to tendon percussion had an average rise time of 10.8 ms and a total duration of approximately 25 ms. With electrical stimulation the rising phase appeared shorter, but it could not be measured accurately due to afferent refractoriness. In single motor units, the rise times of the composite excitatory postsynaptic potentials (EPSPs) set up by subthreshold tendon percussion and by subthreshold electrical stimulation of the tibial nerve were estimated from changes in the probability of discharge of voluntarily activated single motor units. Rise times were significantly longer with tendon percussion (mean +/- SD, 7.1 +/- 2.3 ms; n = 34) than with electrical stimulation (2.4 +/- 1.4 ms; n = 32). In four experiments in which a number of motor units were studied using identical mechanical and identical electrical stimuli, the poststimulus time histograms (PSTHs) for each stimulus were pooled to provide an estimate of the rise time of the excitability change in the motoneuron pool. The mean rise times of these four samples were 10.5 ms with mechanical stimulation and 4.5 ms with electrical stimulation. The spontaneous variability in latency of reflexly activated single motor units was 0.8-3.1 ms (average SD, 0.34 ms) in the tendon jerk, and 0.6-1.4 ms (average SD, 0.19 ms) in the H-reflex. Comparison of these figures with the measurements of rise time given above suggests that the composite EPSPs are larger than the background synaptic noise. With six motor units, the timing of reflex discharge in the tendon jerk when the subject was relaxed was compared with the timing of the change in probability of discharge due to apparently identical percussion when the units were activated voluntarily.(ABSTRACT TRUNCATED AT 400 WORDS)

Strength-duration properties of human peripheral nerve

The strength-duration time constant (tau SD) is a property of nodal membrane and, while it depends on a number of factors, its measurement may shed light on axonal properties when taken in conjunction with measurements of axonal excitability. For example, tau SD increases with demyelination as the exposed membrane is enlarged by inclusion of paranodal and internodal membrane, it decreases with hyperpolarization and it increases with depolarization. The present study was undertaken in 20 normal volunteers to compare strength-duration curves for compound sensory and muscle action potentials, to determine the most appropriate curve fitting equation for the data, and to examine the reproducibility of the calculated time constant on different days, for potentials of different amplitude and at different sites along the nerve. Using a computerized threshold-tracking system, stimulus intensity was adjusted to produce an antidromic compound sensory action potential (CSAP) or an orthodromic muscle action potential of 30% of maximum. Stimulus duration was increased every minute in 20 microseconds steps from 20 microseconds to 1 ms. The time constant for compound sensory potentials (665 +/- 182 microsecond) was longer than that for compound EMG potentials (459 +/- 126 microseconds). Weiss's formula, which relates threshold charge to stimulus duration, provided an accurate fit for the experimental data, and the study validated that, using it, relatively few experimental measurements were required to calculate the time constant. In repeated studies on the same subject, time constants usually differed by < 400 microseconds for sensory axons and < 250 microseconds for motor axons. They were identical at different sites along the nerve and did not alter with the size of the compound action potential. These characteristics suggest that the determinations of strength-duration time constant could be suitable for clinical usage.

A clinical trial of creatine in ALS

BACKGROUND

Mitochondrial dysfunction occurs early in the course of ALS, and the mitochondria may be an important site for therapeutic intervention. Creatine stabilizes the mitochondrial transition pore, and is important in mitochondrial ATP production. In a transgenic mouse model of ALS, administration of creatine prolongs survival and preserves motor function and motor neurons.

METHODS

The authors conducted a randomized double-blind, placebo controlled trial on 104 patients with ALS from 14 sites to evaluate the efficacy of creatine supplementation in ALS. The primary outcome measure was maximum voluntary isometric contraction of eight upper extremity muscles, with secondary outcomes including grip strength, ALS Functional Rating Scale-Revised, and motor unit number estimates. Patients were treated for 6 months, and evaluated monthly.

RESULTS

Creatine was tolerated well, but no benefit of creatine could be demonstrated in any outcome measure. CI analysis showed that the study, although powered to detect a 50% or greater change in rate of decline of muscle strength, actually made an effect size of greater than 23% unlikely. It was also demonstrated that motor unit number estimation was performed with acceptable reproducibility and tolerability, and may be a useful outcome measure in future clinical trials.

CONCLUSION

Any beneficial effect of creatine at 5 g per day in ALS must be small. Other agents should be considered in future studies of therapeutic agents to address mitochondrial dysfunction in ALS. In addition, motor unit number estimation may be a useful outcome measure for future clinical trials in ALS.

The effect of cigarette smoking and smoking cessation on spinal fusion

STUDY DESIGN

The effect of cigarette smoking and smoking cessation on spinal fusion was studied in a retrospective review of 357 patients who had undergone instrumented spinal fusion.

OBJECTIVE

To document the widely assumed but unreported benefit of cigarette smoking cessation on fusion rate and clinical outcome after spinal fusion surgery.

BACKGROUND DATA

Cigarette smoking has been shown to inhibit lumbar spinal fusion and to adversely effect outcome in treatment of lumbar spinal disorders. Prior reports have compared smokers and nonsmokers, as opposed to comparing smokers and quitters.

METHODS

This study retrospectively identified 357 patients who underwent a posterior instrumented fusion at either L4-L5 or L4-S1 between 1992 and 1996. Analysis of the medical record and follow-up telephone surveys were conducted. Clinical outcome and fusion status was analyzed in relation to preoperative and postoperative smoking parameters.

RESULTS

In this study, the nonunion rate was 14.2% for nonsmokers and 26.5% for patients who continued to smoke after surgery (P < 0.05). Patients who quit smoking after surgery for longer than 6 months had a nonunion rate of 17.1%. The nonunion rate was not significantly affected by either the quantity that a patient smoked before surgery or the duration of preoperative smoking abatement. Return-to-work was achieved in 71% of nonsmokers, 53% of nonquitters, and 75% of patients who quit smoking for more than 6 months after surgery.

DISCUSSION

These results validate the hypothetical assumption that postoperative smoking cessation helps to reverse the impact of cigarette smoking on outcome after spinal fusion.

Decline in spindle support to alpha-motoneurones during sustained voluntary contractions

1. To address whether the muscle spindle support to alpha-motoneurones is maintained during prolonged isometric voluntary contractions, the discharge of eighteen muscle spindle afferents, originating in the dorsiflexors of the ankle or toes, was recorded from the common peroneal nerve in eight subjects. Isometric contractions were generally sustained for 1 min, usually below 30% of the maximal voluntary dorsiflexion force. 2. Once the afferent had been identified, subjects were instructed to dorsiflex the foot slowly to recruit the spindle ending, to continue the ramp contraction until a predetermined target force was reached, and then to hold that force until requested to relax. 3. Five muscle spindle afferents maintained a constant discharge frequency during the hold phase of the isometric contraction. Following relaxation of the contraction two spindle afferents from tibialis anterior, exhibited a post-contraction discharge despite the absence of detectable electromyographic activity (EMG). 4. The discharge frequency of most of the spindle afferents (72%) declined progressively during the isometric contraction. The mean firing rates had declined to two-thirds of those at the onset of the contraction by 30 s, and to half after 1 min. The decline in spindle firing rate commenced during the ramp phase of the contraction and was statistically significant by 10 s, when force was held constant. The extent of the decline was greater for those units with the higher initial firing rates and for those units studied after many preceding contractions. 5. In the same contractions a progressive increase in EMG was required to maintain force and consequently the change in EMG was inversely related to the change in spindle discharge. While many mechanisms may contribute to the decline in spindle discharge during a sustained isometric contraction, it is argued that the result will be a progressive disfacilitation of alpha-motoneurones, which may contribute to the decline in motor unit firing rates during a sustained contraction.

Task-dependent reflex responses and movement illusions evoked by galvanic vestibular stimulation in standing humans

1. To identify the vestibular contribution to human standing, responses in leg muscles evoked by galvanic vestibular stimulation were studied. Step impulses of current were applied between the mastoid processes of normal subjects and the effects on the soleus and tibialis anterior electromyograms (EMGs), ankle torque, and body sway were identified by post-stimulus averaging. The responses were measured when subjects stood on a stable platform or on an unstable platform and the effects of eye closure were also assessed. Responses were also recorded during voluntary contraction of the leg muscles and when subjects balanced a load equivalent to their own body in a situation where vestibular postural reflexes would not be useful. 2. At a mean post-stimulus latency of 56 ms, there were reciprocal changes in soleus and tibialis anterior muscle activity followed, at 105 ms, by larger responses of opposite sign. These were termed the short- and middle-latency responses, respectively. Both responses increased with stimulus intensity, but the short-latency response had a higher threshold. The early response had a similar latency to EMG responses evoked by rapid postural perturbations. Both responses were larger when the eyes were closed, but eye closure was associated with increased sway and EMG activity, and the responses were of similar magnitude when scaled to background EMG level. 3. Both short- and middle-latency EMG responses in soleus and tibialis anterior muscles produced small transient postural sways. The transient changes in EMG activity were followed by a larger prolonged sway which was not attributable to the activity in these muscles but rather to reflex or volitional adjustments to movements at other body segments. When subjects were prevented from swaying, the galvanic stimulus produced illusory movements in the opposite direction to the sway evoked when standing, and it is possible that the prolonged sway is a reaction to the illusion of sway. 4. The short- and middle-latency responses were modified during different postural tasks according to the dependence on vestibular reflexes. When the support platform was unstable, the EMG responses to galvanic stimulation were larger. There were no vestibular-evoked responses when seated subjects made voluntary contractions of the leg muscles or when they stood upright with the trunk supported, using the ankles to balance a body-like load.(ABSTRACT TRUNCATED AT 400 WORDS)

The firing rates of human motoneurones voluntarily activated in the absence of muscle afferent feedback

1. To quantify the net influence of muscle afferent feedback on the firing rates of human motoneurones, the discharge frequencies of single motor axons in the common peroneal nerve were recorded during sustained voluntary efforts performed in the absence of feedback from the target muscle. These data were compared with the firing rates of single motor units in the intact tibialis anterior muscle. In five subjects, recordings were made from fifty-two motor axons innervating tibialis anterior during acute deafferentation and paralysis of the dorsiflexor muscles produced by anaesthetic block of the nerve distal to the recording site. 2. Maximal sustainable firing rates were determined for twenty-four motoneurons, twelve of which were classified as relatively low threshold (estimated recruitment level < or = 10% maximal) and six as high threshold. Mean firing rates of the low-threshold motoneurones (21.7 +/- 2.7 Hz; +/- S.E.M.) were significantly higher than those of the high-threshold motoneurones (14.0 +/- 4.4 Hz). The mean firing rate of the twenty-four deafferented motoneurones during maximal efforts to contract the paralysed muscle was 18.6 +/- 1.9 Hz, significantly lower than the maximal firing rates of single motor units recorded from the normally innervated tibialis anterior muscle (28.2 +/- 0.6 Hz). 3. During half-maximal efforts, the mean firing rate of eight deafferented motoneurones (10.8 +/- 1.1 Hz) was significantly lower than that of intact motor units (16.5 +/- 0.2 Hz). A similar finding was apparent during minimal efforts; the mean discharge frequency of seven deafferented motoneurones during weak voluntary efforts was 6.0 +/- 0.9 Hz, compared with 7.3 +/- 0.13 Hz for intact motor units. Overall, the range of motoneurone firing rates (from minimal to maximal levels of voluntary effort) was significantly affected by the acute deafferentation, but was shifted significantly to lower rates. 4. During sustained maximal voluntary efforts of at least 30 s duration the firing rate of deafferented motoneurones decreased over the first 5 s but was then maintained, i.e. there was no progressive decline as occurs with normally innervated motor units during fatiguing contractions. This observation supports a reflex origin for the normal decline in motoneurone discharge. 5. It is concluded that muscle afferents in the common peroneal nerve provide a net facilitation to the tibialis anterior motoneurone pool, reflexly increasing the motor output at all levels of voluntary drive by approximately one-third.

Muscle spindle activity in man during shortening and lengthening contractions

1. The responses of forty-one muscle spindle endings, mostly in tibialis anterior, were studied in human subjects during voluntary movements of the ankle joint performed at various speeds against different external loads. 2. During slow shortening contractions, the discharge rates of spindle endings in the contracting muscle accelerated after the appearance of the first e.m.g. potentials but before sufficient force had been generated to move the limb. With some endings, the discharge rate decreased during the shortening movement while the e.m.g. activity was increasing, but it always remained higher than before the onset of contraction. If the speed of the movement was increased fewer spindle discharges were seen during muscle shortening. If the shortening contraction was opposed by an external load, so that greater effort was required to perform the same movement, more discharges were seen and the discharge pattern became less modulated by the change in muscle length. 3. These findings indicate that during shortening contractions the fusimotor system is activated together with the skeletomotor system. However, the fusimotor drive is generally insufficient to maintain a significant spindle discharge unless movement is slow or the muscle is shortening against an external load. 4. During lengthening contractions the spindle responses were greater than to passive stretch of similar amplitude and velocity, suggesting heightened fusimotor outflow. 5. During shortening and lengthening contractions small iregularities in the speed of movement occurred commonly. Unintended acceleration of a shortening movement caused a pause in spindle firing, and unintended acceleration of a lengthening movement caused an increased discharge from spindle endings. These spindle responses were associated with corresponding alterations in the discharge pattern of the voluntarily activated motor units at latencies consistent with the operation of spinal reflex mechanisms. 6. It is suggested that a functional role for the fusimotor activation during slow shortening contractions is to provide spindle endings with a background discharge so that they can detect irregularities in the movement and initiate the appropriate reflex correction.

Kinaesthetic signals and muscle contraction

Signals generated both peripherally and centrally contribute to the group of sensations termed kinaesthesia. Many experiments report sensations of position and movement under passive relaxed conditions without muscle contraction. However, kinaesthetic acuity is probably of greater functional value when subjects are active rather than passive and, accordingly, movement detection is markedly improved by muscular contraction. One mechanism contributing to this enhancement is likely to involve muscle spindle volleys. When identical microstimulation techniques are applied to skin, joint and muscle spindle endings innervating the hand, some cutaneous afferents and some joint afferents elicit a sensation, but activation of certain other cutaneous afferents and muscle spindle afferents rarely does. Activity in more than one muscle spindle afferent may be required for kinaesthetic sensations, whereas some single cutaneous and joint afferents may have a more 'secure' central projection.

The afferent volleys responsible for spinal proprioceptive reflexes in man

1. To define the neural volleys responsible for the Achilles tendon jerk and the H reflex, muscle afferent activity was recorded using micro-electrodes inserted percutaneously into appropriate fascicles of the tibial nerve in the popliteal fossa.2. The response of soleus muscle afferents to tendon percussion consisted of a dispersed volley, starting 3.5-7.0 ms after percussion, increasing to a peak over 6.5-11.0 ms, and lasting 25-30 ms, depending on the strength of percussion. Electrical stimuli to the sciatic nerve at a level adequate to evoke an H reflex but subthreshold for the M wave produced a more synchronized volley, the fastest fibres of which had conduction velocities of 62-67 m/s, and the slowest 36-45 m/s.3. The wave of acceleration produced by percussion subthreshold for the ankle jerk spread along the skin at over 150 m/s. Midway between the bellies of the gastrocnemii it consisted of a damped oscillation with four to five separate phases and maximum amplitude approximately one-twentieth of that recorded on the Achilles tendon.4. With ten primary spindle endings, tendon percussion subthreshold for the ankle jerk elicited two to five spike discharges per tap, the shortest interspike intervals being 4-7 ms. Tendon percussion elicited single discharges from two Golgi tendon organs, and altered the discharge pattern of a single secondary spindle ending. The degree of dispersion of the multi-unit muscle afferent volley can be explained by the pattern of discharge of primary spindle endings.5. Percussion on the Achilles tendon evoked crisp afferent volleys in recordings from nerve fascicles innervating flexor hallucis longus, tibialis posterior, the intrinsic muscles of the foot and the skin of the foot. Electrical stimuli delivered to the tibial nerve in the popliteal fossa at a level sufficient for the H reflex of soleus produced either a volley in muscle afferents from the intrinsic muscles of the foot or a volley in cutaneous afferents from the foot.6. For comparable stimuli in the two positions, the H reflex was inhibited but the Achilles tendon jerk enhanced when the ankle was dorsiflexed from 105 degrees to 90 degrees .7. The duration of the rise times of the excitatory post-synaptic potentials (e.p.s.p.s) produced in soleus motoneurones by electrical stimulation, and by tendon percussion subthreshold for the H reflex and the ankle jerk respectively, was estimated from post-stimulus time histograms of the discharge of voluntarily activated single motor units in soleus. The mean e.p.s.p. rise times were 1.9 ms for electrical stimulation and 6.6 ms for tendon percussion. There was evidence that the duration of the electrically evoked e.p.s.p. was curtailed by an inhibitory post-synaptic potential (i.p.s.p.) of only slightly longer latency than the e.p.s.p.8. The mechanically induced and electrically induced afferent volleys are not homogeneous volleys in group I a afferents from triceps surae. The afferent volleys differ in so many respects that it is probably invalid to compare the H reflex and tendon jerk as a measure of fusimotor activity. It is suggested that neither reflex can be considered a purely monosynaptic reflex.

Perceptual responses to microstimulation of single afferents innervating joints, muscles and skin of the human hand

1. Microneurographic techniques were used to isolate single afferent axons within cutaneous and motor fascicles of the median and ulnar nerves at the wrist in thirteen subjects. Of the sixty-five identified afferents, eleven innervated the interphalangeal and metacarpophalangeal joints, sixteen innervated muscle spindles, three innervated Golgi tendon organs and thirty-five supplied the glabrous skin of the hand. 2. Intrafascicular stimulation through the recording microelectrode, using trains of constant-voltage positive pulses (0.3-0.8 V, 0.1-0.2 ms, 1-100 Hz) or constant-current biphasic pulses (0.4-13.0 microA, 0.2 ms, 1-100 Hz), evoked specific sensations from sites associated with some afferent species but not others. 3. Microstimulation of eight of the eleven joint afferent sites (73%) evoked specific sensations. With four, subjects reported innocuous deep sensations referred to the relevant joint. With the other four, the subjects reported a sensation of joint displacement that partially reflected the responsiveness of the afferents to joint rotation. 4. Microstimulation of fourteen of the sixteen muscle spindle afferent sites (88%) generated no perceptions when the stimuli did not produce overt movement. However, subjects could correctly detect the slight movements generated when the stimuli excited the motor axons to the parent muscle. 5. With seven of the nine rapidly adapting (type RA or FAI) cutaneous afferents (88%) microstimulation evoked sensations of 'flutter-vibration', and with two of eight slowly adapting (type SAI) afferents (25%) it evoked sensations of 'sustained pressure'. Of the eighteen SAII afferents, which were classified as such by their responses to planar skin stretch, the majority (83%) generated no perceptions, confirming previous work, but three evoked sensations of movements or pressure. 6. The present results suggest a relatively secure transmission of joint afferent traffic to perceptual levels, and it is concluded that the human brain may be able to synthesize meaningful information on joint displacement on the basis of impulses in a single joint afferent. This could partly compensate for the low responsiveness of individual joint afferents within the physiological range of joint displacements. Although single muscle spindle afferents can adequately encode joint position and movement, the results suggest that the brain needs the information from more than one muscle spindle afferent to perceive changes in joint angle.

Responses to passive movement of receptors in joint, skin and muscle of the human hand

1. Microneurographic techniques were employed to record unitary activity from afferents associated with digital joints of six conscious human subjects. Of 120 single afferents sampled from the median and ulnar nerves at the wrist, eighteen (15%) were classified as joint afferents; the majority of the sample (72.5%) were of cutaneous origin, and 12.5% were from muscle spindles and tendon organs. 2. Of the eighteen joint afferents six were tonically active in the rest position of the hand. All except two were recruited or accelerated their background discharge during passive joint movement. Three tonically active afferents were responsive to passive movement throughout the physiological range. The majority of the afferents, including the other three tonically active units, responded only towards the limits of joint rotation. 3. As a group, the sample of joint afferents had a limited capacity to signal the direction of joint movement. Nine of the sixteen joint afferents sensitive to movement responded in two axes of angular displacement, and two responded in all three axes. In any one axis of rotation eight afferents were activated in both directions of movement. However, one afferent, associated with the interphalangeal joint of the thumb, responded uni-directionally throughout the physiological range of joint movement and was thereby capable of adequately encoding joint position and movement. 4. Twenty-one of twenty-nine slowly adapting and eleven of eighteen rapidly adapting cutaneous afferents tested were activated by joint movement, but only towards the limits of joint rotation; half of the thirty-two movement-sensitive afferents were bi-directionally responsive. Muscle spindle afferents responded to stresses applied to the joint only if the resulting passive movement stretched the parent muscle. 5. It is concluded that human joint afferents possess a very limited capacity to provide kinaesthetic information, and that this is likely to be of significance only when muscle spindle afferents cannot contribute to kinaesthesia.

Direct comparison of corticospinal volleys in human subjects to transcranial magnetic and electrical stimulation

1. The effects of graded transcranial magnetic and anodal electrical stimulation of the human motor cortex were compared in human subjects undergoing orthopaedic operations on the spine, before and after withdrawal of volatile anaesthesia. Corticospinal volleys were recorded from the spinal cord in the low-cervical and low-thoracic regions (six subjects) or the mid-thoracic region (two subjects) using bipolar electrodes inserted into the epidural space. 2. Electrical stimuli were delivered using anode at the vertex and cathode 7 cm laterally. The corticospinal volley at threshold consisted of a single deflection with a mean latency to peak of 4.17 ms at the rostral recording site. With further increases in stimulus strength the latency of this D wave shortened in two steps, first by 0.89 ms (seven subjects) and then by a further 0.8 ms (two subjects), indicating that the site of activation of some corticospinal neurones had shifted to deep subcortical sites. 3. When volatile anaesthetics were given, a corticospinal volley could not be defined in three subjects with magnetic stimuli of 70, 80 and 100% maximal stimulator output with the coil at the vertex (Novametrix Magstim 200, round coil, external diameter 14 cm). In the remaining five subjects, the component of lowest threshold was a D wave recorded at the rostral site at 4.0 ms when stimulus intensity was, on average, 70%. With stimuli of 90-100% a total of five small I waves could be defined in the five subjects (i.e. on average one I wave per subject). 4. After cessation of volatile anaesthetics in seven subjects, the thresholds for D and I waves were lower and their amplitudes were greater. The D wave remained the component of lowest threshold in all subjects, appearing at the low-cervical level with magnetic stimuli of 50%. However, in three subjects I waves also appeared at D wave threshold, and the D wave was smaller than with electrical stimulation at I wave threshold. There was no consistent change in latency of the magnetic D wave as stimulus intensity was increased to 100%. 5. These findings suggest that the previously reported difference in latency of the EMG potentials produced in upper-limb muscles by anodal stimulation and magnetic stimulation of the human motor cortex is not because the corticospinal volley induced by magnetic stimulation lacks a D wave.(ABSTRACT TRUNCATED AT 400 WORDS)