Soleus H-reflex amplitude modulation during walking remains physiological during transspinal stimulation in humans

The soleus H-reflex modulation pattern was investigated during stepping following transspinal stimulation over the thoracolumbar region at 15, 30, and 50 Hz with 10 kHz carry-over frequency above and below the paresthesia threshold. The soleus H-reflex was elicited by posterior tibial nerve stimulation with a single 1 ms pulse at an intensity that the M-wave amplitudes ranged from 0 to 15% of the maximal M-wave evoked 80 ms after the test stimulus, and the soleus H-reflex was half the size of the maximal H-reflex evoked on the ascending portion of the recruitment curve. During treadmill walking, the soleus H-reflex was elicited every 2 or 3 steps, and stimuli were randomly dispersed across the step cycle which was divided in 16 equal bins. For each subject and condition, the soleus M-wave and H-reflex were normalized to the maximal M-wave. The soleus background electromyographic (EMG) activity was estimated as the linear envelope for 50 ms duration starting at 100 ms before posterior tibial nerve stimulation for each bin. The gain was determined as the slope of the relationship between the soleus H-reflex and the soleus background EMG activity. The soleus H-reflex phase-dependent amplitude modulation remained unaltered during transspinal stimulation, regardless frequency, or intensity. Similarly, the H-reflex slope and intercept remained the same for all transspinal stimulation conditions tested. Locomotor EMG activity was increased in knee extensor muscles during transspinal stimulation at 30 and 50 Hz throughout the step cycle while no effects were observed in flexor muscles. These findings suggest that transspinal stimulation above and below the paresthesia threshold at 15, 30, and 50 Hz does not block or impair spinal integration of proprioceptive inputs and increases activity of thigh muscles that affect both hip and knee joint movement. Transspinal stimulation may serve as a neurorecovery strategy to augment standing or walking ability in upper motoneuron lesions.

Postsynaptic potentials of soleus motor neurons produced by transspinal stimulation: A human single motor unit study

Transspinal (or transcutaneous spinal cord) stimulation is a non-invasive, cost-effective, easily applied method with great potential as a therapeutic modality for recovering somatic and non-somatic functions in upper motor neuron disorders. However, how transspinal stimulation affects motor neuron depolarization is poorly understood, limiting the development of effective transspinal stimulation protocols for rehabilitation. In this study, we characterized the responses of soleus α motor neurons to single pulse transspinal stimulation using single motor unit discharges as a proxy given the 1:1 discharge activation between the motor neuron and the motor unit. Peristimulus time histogram, peristimulus frequencygram and surface electromyography (sEMG) were used to characterize the postsynaptic potentials of soleus motor neurons. Transspinal stimulation produced short-latency excitatory postsynaptic potentials (EPSPs) followed by two distinct phases of inhibitory postsynaptic potentials (IPSPs) in most soleus motor neurons and only IPSPs in others. Transspinal stimulation generated double discharges at short interspike intervals in a few motor units. The short-latency EPSPs were likely mediated by muscle spindle group Ia and II afferents, and the IPSPs via excitation of group Ib afferents and recurrent collaterals of motor neurons leading to activation of diverse spinal inhibitory interneuronal circuits. Further studies are warranted to understand better how transspinal stimulation affects depolarization of α motor neurons over multiple spinal segments. This knowledge will be seminal for developing effective transspinal stimulation protocols in upper motor neuron lesions.

Tapping into the human spinal locomotor centres with transspinal stimulation

Human locomotion is controlled by spinal neuronal networks of similar properties, function, and organization to those described in animals. Transspinal stimulation affects the spinal locomotor networks and is used to improve standing and walking ability in paralyzed people. However, the function of locomotor centers during transspinal stimulation at different frequencies and intensities is not known. Here, we document the 3D joint kinematics and spatiotemporal gait characteristics during transspinal stimulation at 15, 30, and 50 Hz at sub-threshold and supra-threshold stimulation intensities. We document the temporal structure of gait patterns, dynamic stability of joint movements over stride-to-stride fluctuations, and limb coordination during walking at a self-selected speed in healthy subjects. We found that transspinal stimulation (1) affects the kinematics of the hip, knee, and ankle joints, (2) promotes a more stable coordination at the left ankle, (3) affects interlimb coordination of the thighs, and (4) intralimb coordination between thigh and foot, (5) promotes greater dynamic stability of the hips, (6) increases the persistence of fluctuations in step length variability, and lastly (7) affects mechanical walking stability. These results support that transspinal stimulation is an important neuromodulatory strategy that directly affects gait symmetry and dynamic stability. The conservation of main effects at different frequencies and intensities calls for systematic investigation of stimulation protocols for clinical applications.

Tapping Into the Human Spinal Locomotor Centres With Transspinal Stimulation

Human locomotion is controlled by spinal neuronal networks of similar properties, function, and organization to those described in animals. Transspinal stimulation affects the spinal locomotor networks and is used to improve standing and walking ability in paralyzed people. However, the function of locomotor centers during transspinal stimulation at different frequencies and intensities is not known. Here, we document the 3D joint kinematics and spatiotemporal gait characteristics during transspinal stimulation at 15, 30, and 50 Hz at sub-threshold and supra-threshold stimulation intensities. We document the temporal structure of gait patterns, dynamic stability of joint movements over stride-to-stride fluctuations, and limb coordination during walking at a self-selected speed in healthy subjects. We found that transspinal stimulation 1) affects the kinematics of the hip, knee, and ankle joints, 2) promotes a more stable coordination at the left ankle, 3) improves interlimb coordination of the thighs, 4) improves intralimb coordination between thigh and foot, 5) promotes greater dynamic stability of the hips, and lastly 6) affects the mechanical stability of the joints. These results support that transspinal stimulation is an important neuromodulatory strategy that directly affects gait symmetry and dynamic stability. The conservation of main effects at different frequencies and intensities calls for systematic investigation of stimulation protocols for clinical applications.

Priming locomotor training with transspinal stimulation in people with spinal cord injury: study protocol of a randomized clinical trial

BACKGROUND

The seemingly simple tasks of standing and walking require continuous integration of complex spinal reflex circuits between descending motor commands and ascending sensory inputs. Spinal cord injury greatly impairs standing and walking ability, but both improve with locomotor training. However, even after multiple locomotor training sessions, abnormal muscle activity and coordination persist. Thus, locomotor training alone cannot fully optimize the neuronal plasticity required to strengthen the synapses connecting the brain, spinal cord, and local circuits and potentiate neuronal activity based on need. Transcutaneous spinal cord (transspinal) stimulation alters motoneuron excitability over multiple segments by bringing motoneurons closer to threshold, a prerequisite for effectively promoting spinal locomotor network neuromodulation and strengthening neural connectivity of the injured human spinal cord. Importantly, whether concurrent treatment with transspinal stimulation and locomotor training maximizes motor recovery after spinal cord injury is unknown.

METHODS

Forty-five individuals with chronic spinal cord injury are receiving 40 sessions of robotic gait training primed with 30 Hz transspinal stimulation at the Thoracic 10 vertebral level. Participants are randomized to receive 30 min of active or sham transspinal stimulation during standing or active transspinal stimulation while supine followed by 30 min of robotic gait training. Over the course of locomotor training, the body weight support, treadmill speed, and leg guidance force are adjusted as needed for each participant based on absence of knee buckling during the stance phase and toe dragging during the swing phase. At baseline and after completion of all therapeutic sessions, neurophysiological recordings registering corticospinal and spinal neural excitability changes along with clinical assessment measures of standing and walking, and autonomic function via questionnaires regarding bowel, bladder, and sexual function are taken.

DISCUSSION

The results of this mechanistic randomized clinical trial will demonstrate that tonic transspinal stimulation strengthens corticomotoneuronal connectivity and dynamic neuromodulation through posture-dependent corticospinal and spinal neuroplasticity. We anticipate that this mechanistic clinical trial will greatly impact clinical practice because, in real-world clinical settings, noninvasive transspinal stimulation can be more easily and widely implemented than invasive epidural stimulation. Additionally, by applying multiple interventions to accelerate motor recovery, we are employing a treatment regimen that reflects a true clinical approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04807764 . Registered on March 19, 2021.

Priming locomotor training with transspinal stimulation in people with spinal cord injury: study protocol of a randomized clinical trial

Background

The seemingly simple tasks of standing and walking require continuous integration of complex spinal reflex circuits between descending motor commands and ascending sensory inputs. Spinal cord injury greatly impairs standing and walking ability, but both improve with locomotor training. However, even after multiple locomotor training sessions, abnormal muscle activity and coordination persist. Thus, locomotor training alone cannot fully optimize the neuronal plasticity required to strengthen the synapses connecting the brain, spinal cord, and local circuits and potentiate neuronal activity based on need. Transcutaneous spinal cord (transspinal) stimulation alters motoneuron excitability over multiple segments by bringing motoneurons closer to threshold, a prerequisite for effectively promoting spinal locomotor network neuromodulation and strengthening neural connectivity of the injured human spinal cord. Importantly, whether concurrent treatment with transspinal stimulation and locomotor training maximizes motor recovery after spinal cord injury is unknown.

Methods

Forty-five individuals with chronic spinal cord injury are receiving 40 sessions of robotic gait training primed with 30 Hz transspinal stimulation at the Thoracic 10 vertebral level. Participants are randomized to receive 30-minutes of active or sham transspinal stimulation during standing or active transspinal stimulation while supine followed by 30-minutes of robotic gait training. Over the course of locomotor training, the body weight support, treadmill speed, and leg guidance force are adjusted as needed for each participant based on absence of knee buckling during the stance phase and toe dragging during the swing phase. At baseline and after completion of all therapeutic sessions, neurophysiological recordings registering corticospinal and spinal neural excitability changes along with clinical assessment measures of standing and walking, and autonomic function via questionnaires regarding bowel, bladder and sexual function are taken.

Discussion

The results of this mechanistic randomized clinical trial will demonstrate that tonic transspinal stimulation strengthens corticomotoneuronal connectivity and dynamic neuromodulation through posture-dependent corticospinal and spinal neuroplasticity. We anticipate that this mechanistic clinical trial will greatly impact clinical practice because in real-world clinical settings, noninvasive transspinal stimulation can be more easily and widely implemented than invasive epidural stimulation. Additionally, by applying multiple interventions to accelerate motor recovery, we are employing a treatment regimen that reflects a true clinical approach.

Trial registration

ClinicalTrials.gov: NCT04807764; Registered on March 19, 2021.

Physiological effects of cathodal electrode configuration for transspinal stimulation in humans

Transspinal stimulation modulates neuronal excitability and promotes recovery in upper motoneuron lesions. The recruitment input-output curves of transspinal evoked potentials (TEPs) recorded from knee and ankle muscles, and their susceptibility to spinal inhibition, were recorded when the position, size, and number of the cathode electrode were arranged in four settings or protocols (Ps). The four Ps were the following: 1) one rectangular electrode placed at midline (KNIKOU-LAB4Recovery or K-LAB4Recovery; P-KLAB), 2) one square electrode placed at midline (P-2), 3) two square electrodes 1 cm apart placed at midline (P-3), and 4) one square electrode placed on each paravertebral side (P-4). P-KLAB and P-3 required less current to reach TEP threshold or maximal amplitudes. A rightward shift in TEP recruitment curves was evident for P-4, whereas the slope was increased for P-2 and P-4 compared with P-KLAB and P-3. TEP depression upon single and paired transspinal stimuli was pronounced in ankle TEPs but was less prominent in knee TEPs. TEP depression induced by single transspinal stimuli at 1.0 Hz was similar for most TEPs across protocols, but TEP depression induced by paired transspinal stimuli was different between protocols and was replaced by facilitation at 100-ms interstimulus interval for P-4. Our results suggest that P-KLAB and P-3 are preferred based on excitability threshold of motoneurons. P-KLAB produced more TEP depression, thereby maximizing the engagement of spinal neuronal pathways. We recommend P-KLAB to study neurophysiological mechanisms underlying transspinal stimulation or when used as a neuromodulation method for recovery in neurological disorders.NEW & NOTEWORTHY Transspinal stimulation with a rectangular cathode electrode (P-KLAB) requires less current to produce transspinal evoked potentials and maximizes spinal inhibition. We recommend P-KLAB for neurophysiological studies or when used as a neuromodulation method to enhance motor output and normalize muscle tone in neurological disorders.

Brain and spinal cord paired stimulation coupled with locomotor training facilitates motor output in human spinal cord injury

Combined interventions for neuromodulation leading to neurorecovery have gained great attention by researchers to resemble clinical rehabilitation approaches. In this randomized clinical trial, we established changes in the net output of motoneurons innervating multiple leg muscles during stepping when transcranial magnetic stimulation (TMS) of the primary motor cortex was paired with transcutaneous spinal (transspinal) stimulation over the thoracolumbar region during locomotor training. TMS was delivered before (TMS-transspinal) or after (transspinal-TMS) transspinal stimulation during the stance phase of the less impaired leg. Ten individuals with chronic incomplete or complete SCI received at least 20 sessions of training. Each session consisted of 240 paired stimuli delivered over 10-min blocks for 1 h during robotic assisted step training on a motorized treadmill. Body weight support, leg guidance force and treadmill speed were adjusted based on each subject's ability to step without knee buckling or toe dragging. Most transspinal evoked potentials (TEPs) recorded before and after each intervention from ankle and knee muscles during assisted stepping were modulated in a phase-dependent pattern. Transspinal-TMS and locomotor training affected motor neuron output of knee and ankle muscles with ankle TEPs to be modulated in a phase-dependent manner. TMS-transspinal and locomotor training increased motor neuron output for knee but not for ankle muscles. Our results support that targeted brain and spinal cord stimulation alters responsiveness of neurons over multiple spinal segments in people with chronic SCI. Noninvasive stimulation of the brain and spinal cord along with locomotor training is a novel neuromodulation method that can become a promising modality for rehabilitation in humans after SCI.

Transspinal stimulation and step training alter function of spinal networks in complete spinal cord injury

STUDY DESIGN

Pilot study (case series).

OBJECTIVE

The objective of this study was to establish spinal neurophysiological changes following high-frequency transspinal stimulation during robot-assisted step training in individuals with chronic motor complete spinal cord injury (SCI).

SETTING

University research laboratory (Klab4Recovery).

METHODS

Four individuals with motor complete SCI received an average of 18 sessions of transspinal stimulation over the thoracolumbar region with a pulse train at 333 Hz during robotic-assisted step training. Each session lasted ~1 h, with an average of 240 stimulations delivered during each training session. Before and after the combined intervention, we evaluated the amplitude modulation of the long-latency tibialis anterior (TA) flexion reflex and transspinal evoked potentials (TEP) recorded from flexors and extensors during assisted stepping, and the TEP recruitment curves at rest.

RESULTS

The long-latency TA flexion reflex was depressed in all phases of the step cycle and the phase-dependent amplitude modulation of TEPs was altered during assisted stepping, while spinal motor output based on TEP recruitment curves was increased after the combined intervention.

CONCLUSION

This is the first study documenting noninvasive transspinal stimulation coupled with locomotor training depresses flexion reflex excitability and concomitantly increases motoneuron output over multiple spinal segments for both flexors and extensors in people with motor complete SCI. While both transspinal stimulation and locomotor training may act via similar activity-dependent neuroplasticity mechanisms, combined interventions for rehabilitation of neurological disorders has not been systematically assessed. Our current findings support locomotor training induced neuroplasticity may be augmented with transspinal stimulation.

Neurophysiological Changes After Paired Brain and Spinal Cord Stimulation Coupled With Locomotor Training in Human Spinal Cord Injury

Neurophysiological changes that involve activity-dependent neuroplasticity mechanisms via repeated stimulation and locomotor training are not commonly employed in research even though combination of interventions is a common clinical practice. In this randomized clinical trial, we established neurophysiological changes when transcranial magnetic stimulation (TMS) of the motor cortex was paired with transcutaneous thoracolumbar spinal (transspinal) stimulation in human spinal cord injury (SCI) delivered during locomotor training. We hypothesized that TMS delivered before transspinal (TMS-transspinal) stimulation promotes functional reorganization of spinal networks during stepping. In this protocol, TMS-induced corticospinal volleys arrive at the spinal cord at a sufficient time to interact with transspinal stimulation induced depolarization of alpha motoneurons over multiple spinal segments. We further hypothesized that TMS delivered after transspinal (transspinal-TMS) stimulation induces less pronounced effects. In this protocol, transspinal stimulation is delivered at time that allows transspinal stimulation induced action potentials to arrive at the motor cortex and affect descending motor volleys at the site of their origin. Fourteen individuals with motor incomplete and complete SCI participated in at least 25 sessions. Both stimulation protocols were delivered during the stance phase of the less impaired leg. Each training session consisted of 240 paired stimuli delivered over 10-min blocks. In transspinal-TMS, the left soleus H-reflex increased during the stance-phase and the right soleus H-reflex decreased at mid-swing. In TMS-transspinal no significant changes were found. When soleus H-reflexes were grouped based on the TMS-targeted limb, transspinal-TMS and locomotor training promoted H-reflex depression at swing phase, while TMS-transspinal and locomotor training resulted in facilitation of the soleus H-reflex at stance phase of the step cycle. Furthermore, both transspinal-TMS and TMS-transspinal paired-associative stimulation (PAS) and locomotor training promoted a more physiological modulation of motor activity and thus depolarization of motoneurons during assisted stepping. Our findings support that targeted non-invasive stimulation of corticospinal and spinal neuronal pathways coupled with locomotor training produce neurophysiological changes beneficial to stepping in humans with varying deficits of sensorimotor function after SCI.

Neuronal Actions of Transspinal Stimulation on Locomotor Networks and Reflex Excitability During Walking in Humans With and Without Spinal Cord Injury

This study investigated the neuromodulatory effects of transspinal stimulation on soleus H-reflex excitability and electromyographic (EMG) activity during stepping in humans with and without spinal cord injury (SCI). Thirteen able-bodied adults and 5 individuals with SCI participated in the study. EMG activity from both legs was determined for steps without, during, and after a single-pulse or pulse train transspinal stimulation delivered during stepping randomly at different phases of the step cycle. The soleus H-reflex was recorded in both subject groups under control conditions and following single-pulse transspinal stimulation at an individualized exactly similar positive and negative conditioning-test interval. The EMG activity was decreased in both subject groups at the steps during transspinal stimulation, while intralimb and interlimb coordination were altered only in SCI subjects. At the steps immediately after transspinal stimulation, the physiological phase-dependent EMG modulation pattern remained unaffected in able-bodied subjects. The conditioned soleus H-reflex was depressed throughout the step cycle in both subject groups. Transspinal stimulation modulated depolarization of motoneurons over multiple segments, limb coordination, and soleus H-reflex excitability during assisted stepping. The soleus H-reflex depression may be the result of complex spinal inhibitory interneuronal circuits activated by transspinal stimulation and collision between orthodromic and antidromic volleys in the peripheral mixed nerve. The soleus H-reflex depression by transspinal stimulation suggests a potential application for normalization of spinal reflex excitability after SCI.

Rectus femoris hyperreflexia contributes to Stiff-Knee gait after stroke

Background

Stiff-Knee gait (SKG) after stroke is often accompanied by decreased knee flexion angle during the swing phase. The decreased knee flexion has been hypothesized to originate from excessive quadriceps activation. However, it is unclear whether hyperreflexia plays a role in this activation. The goal of this study was to establish the relationship between quadriceps hyperreflexia and knee flexion angle during walking in post-stroke SKG.

Methods

The rectus femoris (RF) H-reflex was recorded in 10 participants with post-stroke SKG and 10 healthy controls during standing and walking at the pre-swing phase. In order to attribute the pathological neuromodulation to quadriceps muscle hyperreflexia and activation, healthy individuals voluntarily increased quadriceps activity using electromyographic (EMG) feedback during standing and pre-swing upon RF H-reflex elicitation.

Results

We observed a negative correlation (R = − 0.92, p = 0.001) between knee flexion angle and RF H-reflex amplitude in post-stroke SKG. In contrast, H-reflex amplitude in healthy individuals in presence (R = 0.47, p = 0.23) or absence (R = − 0.17, p = 0.46) of increased RF muscle activity was not correlated with knee flexion angle. We observed a body position-dependent RF H-reflex modulation between standing and walking in healthy individuals with voluntarily increased RF activity (d = 2.86, p = 0.007), but such modulation was absent post-stroke (d = 0.73, p = 0.296).

Conclusions

RF reflex modulation is impaired in post-stroke SKG. The strong correlation between RF hyperreflexia and knee flexion angle indicates a possible regulatory role of spinal reflex excitability in post-stroke SKG. Interventions targeting quadriceps hyperreflexia could help elucidate the causal role of hyperreflexia on knee joint function in post-stroke SKG.

Transspinal stimulation downregulates activity of flexor locomotor networks during walking in humans

The objective of this study was to establish the effects of transspinal stimulation on short-latency tibialis anterior (TA) flexion reflex during walking in healthy humans. Single pulse transspinal stimulation was delivered at a conditioning-test (C-T) interval either after (~20 ms) or simultaneously with the last pulse of the pulse train (0 ms) delivered to the medial arch of the right foot. Transspinal stimulation was delivered at sub- and supra-threshold intensities of the spinally-mediated TA transspinal evoked potential. Stimulation was delivered randomly at different phases of the step cycle, based on the foot switch threshold signal, which was divided into 16 equal bins. The TA flexion reflex facilitation under control conditions occurred at heel contact and then progressively from late stance phase reaching its peak at early and late swing phases. Transspinal stimulation at a negative and suprathreshold 0 ms C-T interval depressed flexion reflex excitability at all phases of the step cycle. The short-latency TA flexion reflex depression was possibly mediated through spinal inhibitory interneurons acting at both pre- and post- motoneuronal sites or by transspinal stimulation affecting directly the activity of the flexor half spinal center. These results reveal direct actions of transspinal stimulation on human spinal locomotor networks.

Transspinal stimulation decreases corticospinal excitability and alters the function of spinal locomotor networks

Locomotion requires the continuous integration of descending motor commands and sensory inputs from the legs by spinal central pattern generator circuits. Modulation of spinal neural circuits by transspinal stimulation is well documented, but how transspinal stimulation affects corticospinal excitability during walking in humans remains elusive. We measured the motor evoked potentials (MEPs) at multiple phases of the step cycle conditioned with transspinal stimulation delivered at sub- and suprathreshold intensities of the spinally mediated transspinal evoked potential (TEP). Transspinal stimulation was delivered before or after transcranial magnetic stimulation during which summation between MEP and TEP responses in the surface EMG was absent or present. Relationships between MEP amplitude and background EMG activity, silent period duration, and phase-dependent EMG amplitude modulation during and after stimulation were also determined. Ankle flexor and extensor MEPs were depressed by suprathreshold transspinal stimulation when descending volleys were timed to interact with transspinal stimulation-induced motoneuron depolarization at the spinal cord. MEP depression coincided with decreased MEP gain, unaltered MEP threshold, and unaltered silent period duration. Locomotor EMG activity of bilateral knee and ankle muscles was significantly depressed during the step at which transspinal stimulation was delivered but fully recovered at the subsequent step. The results support a model in which MEP depression by transspinal stimulation occurs via subcortical or spinal mechanisms. Transspinal stimulation disrupts the locomotor output of flexor and extensor motoneurons initially, but the intact nervous system has the ability to rapidly overcome this pronounced locomotor adaptation. In conclusion, transspinal stimulation directly affects spinal locomotor centers in healthy humans.NEW & NOTEWORTHY Lumbar transspinal stimulation decreases ankle flexor and extensor motor evoked potentials (MEPs) during walking. The MEP depression coincides with decreased MEP gain, unaltered MEP threshold changes, and unaltered silent period duration. These findings indicate that MEP depression is subcortical or spinal in origin. Healthy subjects could rapidly overcome the pronounced depression of muscle activity during the step at which transspinal stimulation was delivered. Thus, transspinal stimulation directly affects the function of spinal locomotor networks in healthy humans.

Transspinal stimulation increases motoneuron output of multiple segments in human spinal cord injury

Targeted neuromodulation strategies that strengthen neuronal activity are in great need for restoring sensorimotor function after chronic spinal cord injury (SCI). In this study, we established changes in the motoneuron output of individuals with and without SCI after repeated noninvasive transspinal stimulation at rest over the thoracolumbar enlargement, the spinal location of leg motor circuits. Cases of motor incomplete and complete SCI were included to delineate potential differences when corticospinal motor drive is minimal. All 10 SCI and 10 healthy control subjects received daily monophasic transspinal stimuli of 1-ms duration at 0.2 Hz at right soleus transspinal evoked potential (TEP) subthreshold and suprathreshold intensities at rest. Before and two days after cessation of transspinal stimulation, we determined changes in TEP recruitment input-output curves, TEP amplitude at stimulation frequencies of 0.1, 0.125, 0.2, 0.33 and 1.0 Hz, and TEP postactivation depression upon transspinal paired stimuli at interstimulus intervals of 60, 100, 300, and 500 ms. TEPs were recorded at rest from bilateral ankle and knee flexor/extensor muscles. Repeated transspinal stimulation increased the motoneuron output over multiple segments. In control and complete SCI subjects, motoneuron output increased for knee muscles, while in motor incomplete SCI subjects motoneuron output increased for both ankle and knee muscles. In control subjects, TEPs homosynaptic and postactivation depression were present at baseline, and were potentiated for the distal ankle or knee flexor muscles. TEPs homosynaptic and postactivation depression at baseline depended on the completeness of the SCI, with minimal changes observed after transspinal stimulation. These results indicate that repeated transspinal stimulation increases spinal motoneuron responsiveness of ankle and knee muscles in the injured human spinal cord, and thus can promote motor recovery. This noninvasive neuromodulation method is a promising modality for promoting functional neuroplasticity after SCI.

Neural interactions between transspinal evoked potentials and muscle spindle afferents in humans

The objective of this study was to establish neural interactions between transspinal evoked potentials (TEPs) and muscle spindle group Ia afferents in healthy humans. Soleus H-reflexes were assessed following transspinal stimulation at conditioning-test (C-T) intervals that ranged from negative to positive 100 ms. TEPs were recorded from the right and left ankle/knee flexor and extensor muscles, and their amplitude was assessed following stimulation of soleus muscle spindle group Ia afferents at similar C-T intervals. Transspinal conditioning stimulation produced a short-latency, long-lasting soleus H-reflex depression. Excitation of muscle spindle group Ia afferents produced depression of ipsilateral ankle TEPs and medium-latency facilitation of the ipsilateral knee TEPs. At specific C-T intervals, the soleus H-reflex and ipsilateral ankle TEPs were summated based on their relative onset and duration. No changes were observed in the contralateral TEPs. These effects were exerted at both peripheral and spinal levels. Both transspinal and muscle spindle group Ia afferent stimulation produce long-lasting depression of the soleus H-reflex and TEPs, respectively. Transspinal stimulation may promote targeted neuromodulation and can be utilized in upper motoneuron lesions to normalize spinal reflex hyper-excitability and alter excitation thresholds of peripheral nerve axons.

Spinal Control of Locomotion: Individual Neurons, Their Circuits and Functions

Systematic research on the physiological and anatomical characteristics of spinal cord interneurons along with their functional output has evolved for more than one century. Despite significant progress in our understanding of these networks and their role in generating and modulating movement, it has remained a challenge to elucidate the properties of the locomotor rhythm across species. Neurophysiological experimental evidence indicates similarities in the function of interneurons mediating afferent information regarding muscle stretch and loading, being affected by motor axon collaterals and those mediating presynaptic inhibition in animals and humans when their function is assessed at rest. However, significantly different muscle activation profiles are observed during locomotion across species. This difference may potentially be driven by a modified distribution of muscle afferents at multiple segmental levels in humans, resulting in an altered interaction between different classes of spinal interneurons. Further, different classes of spinal interneurons are likely activated or silent to some extent simultaneously in all species. Regardless of these limitations, continuous efforts on the function of spinal interneuronal circuits during mammalian locomotion will assist in delineating the neural mechanisms underlying locomotor control, and help develop novel targeted rehabilitation strategies in cases of impaired bipedal gait in humans. These rehabilitation strategies will include activity-based therapies and targeted neuromodulation of spinal interneuronal circuits via repetitive stimulation delivered to the brain and/or spinal cord.

MRI measures of fat infiltration in the lower extremities following motor incomplete spinal cord injury: reliability and potential implications for muscle activation

Muscle fat infiltration (MFI) is an expected consequence of incomplete spinal cord injury (iSCI). The MFI magnitude may have clinical value in determining functional recovery. However, there is a lack of understanding of how MFI relates to the volitional muscle activity in people with motor incomplete spinal cord injury (iSCI). Five iSCI and 5 uninjured age-matched control subjects participated in the study. In this preliminary study, we established the reliability of MFI quantification of select lower extremity muscles across different raters. Secondly, we assessed the magnitude and distribution of MFI in the lower legs of iSCI and uninjured control participants. Thirdly, we explored the relationship between MFI in the plantar flexor muscles and the ability to volitionally activate these muscles. High levels of inter-rater reliability were observed. The iSCI group had significantly elevated and a vastly different MFI distribution in the lower leg muscles compared to healthy controls. MFI was negatively correlated with volitional activation in iSCI. Our preliminary results sanction the importance of lower extremity MFI quantification as a potential measure in determining the functional outcomes in iSCI, and the subsequent pathological sequelae.

Remodeling Brain Activity by Repetitive Cervicothoracic Transspinal Stimulation after Human Spinal Cord Injury

Interventions that can produce targeted brain plasticity after human spinal cord injury (SCI) are needed for restoration of impaired movement in these patients. In this study, we tested the effects of repetitive cervicothoracic transspinal stimulation in one person with cervical motor incomplete SCI on cortical and corticospinal excitability, which were assessed via transcranial magnetic stimulation with paired and single pulses, respectively. We found that repetitive cervicothoracic transspinal stimulation potentiated intracortical facilitation in flexor and extensor wrist muscles, recovered intracortical inhibition in the more impaired wrist flexor muscle, increased corticospinal excitability bilaterally, and improved voluntary muscle strength. These effects may have been mediated by improvements in cortical integration of ascending sensory inputs and strengthening of corticospinal connections. Our novel therapeutic intervention opens new avenues for targeted brain neuromodulation protocols in individuals with cervical motor incomplete SCI.

Paired associative transspinal and transcortical stimulation produces plasticity in human cortical and spinal neuronal circuits

Anatomical, physiological, and functional connectivity exists between the neurons of the primary motor cortex (M1) and spinal cord. Paired associative stimulation (PAS) produces enduring changes in M1, based on the Hebbian principle of associative plasticity. The present study aimed to establish neurophysiological changes in human cortical and spinal neuronal circuits by pairing noninvasive transspinal stimulation with transcortical stimulation via transcranial magnetic stimulation (TMS). We delivered paired transspinal and transcortical stimulation for 40 min at precise interstimulus intervals, with TMS being delivered after (transspinal-transcortical PAS) or before (transcortical-transspinal PAS) transspinal stimulation. Transspinal-transcortical PAS markedly decreased intracortical inhibition, increased intracortical facilitation and M1 excitability with concomitant decreases of motor threshold, and reduced the soleus Hoffmann's reflex (H-reflex) low frequency-mediated homosynaptic depression. Transcortical-transspinal PAS did not affect intracortical circuits, decreased M1 excitability, and reduced the soleus H-reflex-paired stimulation pulses' mediated postactivation depression. Both protocols affected the excitation threshold of group Ia afferents and motor axons. These findings clearly indicate that the pairing of transspinal with transcortical stimulation produces cortical and spinal excitability changes based on the timing interval and functional network interactions between the two associated inputs. This new PAS paradigm may constitute a significant neuromodulation method with physiological impact, because it can be used to alter concomitantly excitability of intracortical circuits, corticospinal neurons, and spinal inhibition in humans.

A Review on Locomotor Training after Spinal Cord Injury: Reorganization of Spinal Neuronal Circuits and Recovery of Motor Function

Locomotor training is a classic rehabilitation approach utilized with the aim of improving sensorimotor function and walking ability in people with spinal cord injury (SCI). Recent studies have provided strong evidence that locomotor training of persons with clinically complete, motor complete, or motor incomplete SCI induces functional reorganization of spinal neuronal networks at multisegmental levels at rest and during assisted stepping. This neuronal reorganization coincides with improvements in motor function and decreased muscle cocontractions. In this review, we will discuss the manner in which spinal neuronal circuits are impaired and the evidence surrounding plasticity of neuronal activity after locomotor training in people with SCI. We conclude that we need to better understand the physiological changes underlying locomotor training, use physiological signals to probe recovery over the course of training, and utilize established and contemporary interventions simultaneously in larger scale research studies. Furthermore, the focus of our research questions needs to change from feasibility and efficacy to the following: what are the physiological mechanisms that make it work and for whom? The aforementioned will enable the scientific and clinical community to develop more effective rehabilitation protocols maximizing sensorimotor function recovery in people with SCI.

Transspinal constant-current long-lasting stimulation: a new method to induce cortical and corticospinal plasticity

Functional neuroplasticity in response to stimulation and motor training is a well-established phenomenon. Transcutaneous stimulation of the spine is used mostly to alleviate pain, but it may also induce functional neuroplasticity, because the spinal cord serves as an integration center for descending and ascending neuronal signals. In this work, we examined whether long-lasting noninvasive cathodal (c-tsCCS) and anodal (a-tsCCS) transspinal constant-current stimulation over the thoracolumbar enlargement can induce cortical, corticospinal, and spinal neuroplasticity. Twelve healthy human subjects, blind to the stimulation protocol, were randomly assigned to 40 min of c-tsCCS or a-tsCCS. Before and after transspinal stimulation, we established the afferent-mediated motor evoked potential (MEP) facilitation and the subthreshold transcranial magnetic stimulation (TMS)-mediated flexor reflex facilitation. Recruitment input-output curves of MEPs and transspinal evoked potentials (TEPs) and postactivation depression of the soleus H reflex and TEPs was also established. We demonstrate that both c-tsCCS and a-tsCCS decrease the afferent-mediated MEP facilitation and alter the subthreshold TMS-mediated flexor reflex facilitation in a polarity-dependent manner. Both c-tsCCS and a-tsCCS increased the tibialis anterior MEPs recorded at 1.2 MEP resting threshold, intermediate, and maximal intensities and altered the recruitment input-output curve of TEPs in a muscle- and polarity-dependent manner. Soleus H-reflex postactivation depression was reduced after a-tsCCS and remained unaltered after c-tsCCS. No changes were found in the postactivation depression of TEPs after c-tsCCS or a-tsCCS. Our findings reveal that c-tsCCS and a-tsCCS have distinct effects on cortical and corticospinal excitability. This method can be utilized to induce targeted neuroplasticity in humans.

Convergence of flexor reflex and corticospinal inputs on tibialis anterior network in humans

OBJECTIVE

Integration between descending and ascending inputs at supraspinal and spinal levels is a key characteristic of neural control of movement. In this study, we characterized convergence of the flexor reflex and corticospinal inputs on the tibialis anterior (TA) network in healthy human subjects. Specifically, we characterized the modulation profiles of the spinal TA flexor reflex following subthreshold and suprathreshold transcranial magnetic stimulation (TMS). We also characterized the modulation profiles of the TA motor evoked potentials (MEPs) following medial arch foot stimulation at sensory and above reflex threshold.

METHODS

TA flexor reflexes were evoked following stimulation of the medial arch of the foot with a 30 ms pulse train at innocuous intensities. TA MEPs were evoked following TMS of the leg motor cortex area.

RESULTS

TMS at 0.7 and at 1.2 MEP resting threshold increased the TA flexor reflex when TMS was delivered 40-100 ms after foot stimulation, and decreased the TA flexor reflex when TMS was delivered 25-110 ms before foot stimulation. Foot stimulation at sensory and above flexor reflex threshold induced a similar time-dependent modulation in resting TA MEPs, that were facilitated when foot stimulation was delivered 40-100 ms before TMS. The flexor reflex and MEPs recorded from the medial hamstring muscle were modulated in a similar manner to that observed for the TA flexor reflex and MEP.

CONCLUSION

Cutaneomuscular afferents from the distal foot can increase the output of the leg motor cortex area. Descending motor volleys that directly or indirectly depolarize flexor motoneurons increase the output of the spinal FRA interneuronal network. The parallel facilitation of flexor MEPs and flexor reflexes is likely cortical in origin.

SIGNIFICANCE

Afferent mediated facilitation of corticospinal excitability can be utilized to strengthen motor cortex output in neurological disorders.

Corticospinal and reciprocal inhibition actions on human soleus motoneuron activity during standing and walking

Reciprocal Ia inhibition constitutes a key segmental neuronal pathway for coordination of antagonist muscles. In this study, we investigated the soleus H-reflex and reciprocal inhibition exerted from flexor group Ia afferents on soleus motoneurons during standing and walking in 15 healthy subjects following transcranial magnetic stimulation (TMS). The effects of separate TMS or deep peroneal nerve (DPN) stimulation and the effects of combined (TMS + DPN) stimuli on the soleus H-reflex were assessed during standing and at mid- and late stance phases of walking. Subthreshold TMS induced short-latency facilitation on the soleus H-reflex that was present during standing and at midstance but not at late stance of walking. Reciprocal inhibition was increased during standing and at late stance but not at the midstance phase of walking. The effects of combined TMS and DPN stimuli on the soleus H-reflex significantly changed between tasks, resulting in an extra facilitation of the soleus H-reflex during standing and not during walking. Our findings indicate that corticospinal inputs and Ia inhibitory interneurons interact at the spinal level in a task-dependent manner, and that corticospinal modulation of reciprocal Ia inhibition is stronger during standing than during walking.

Locomotor training improves reciprocal and nonreciprocal inhibitory control of soleus motoneurons in human spinal cord injury

Pathologic reorganization of spinal networks and activity-dependent plasticity are common neuronal adaptations after spinal cord injury (SCI) in humans. In this work, we examined changes of reciprocal Ia and nonreciprocal Ib inhibition after locomotor training in 16 people with chronic SCI. The soleus H-reflex depression following common peroneal nerve (CPN) and medial gastrocnemius (MG) nerve stimulation at short conditioning-test (C-T) intervals was assessed before and after training in the seated position and during stepping. The conditioned H reflexes were normalized to the unconditioned H reflex recorded during seated. During stepping, both H reflexes were normalized to the maximal M wave evoked at each bin of the step cycle. In the seated position, locomotor training replaced reciprocal facilitation with reciprocal inhibition in all subjects, and Ib facilitation was replaced by Ib inhibition in 13 out of 14 subjects. During stepping, reciprocal inhibition was decreased at early stance and increased at midswing in American Spinal Injury Association Impairment Scale C (AIS C) and was decreased at midstance and midswing phases in AIS D after training. Ib inhibition was decreased at early swing and increased at late swing in AIS C and was decreased at early stance phase in AIS D after training. The results of this study support that locomotor training alters postsynaptic actions of Ia and Ib inhibitory interneurons on soleus motoneurons at rest and during stepping and that such changes occur in cases with limited or absent supraspinal inputs.

Locomotor training modifies soleus monosynaptic motoneuron responses in human spinal cord injury

The objective of this study was to assess changes in monosynaptic motoneuron responses to stimulation of Ia afferents after locomotor training in individuals with chronic spinal cord injury (SCI). We hypothesized that locomotor training modifies the amplitude of the soleus monosynaptic motoneuron responses in a body position-dependent manner. Fifteen individuals with chronic clinical motor complete or incomplete SCI received an average of 45 locomotor training sessions. The soleus H-reflex and M-wave recruitment curves were assembled using data collected in both the right and left legs, with subjects seated and standing, before and after training. The soleus H-reflexes and M-waves, measured as peak-to-peak amplitudes, were normalized to the maximal M-wave (M(max)). Stimulation intensities were normalized to 50% M(max) stimulus intensity. A sigmoid function was also fitted to the normalized soleus H-reflexes on the ascending limb of the recruitment curve. After training, soleus H-reflex excitability was increased in both legs in AIS C subjects, and remained unchanged in AIS A-B and AIS D subjects during standing. When subjects were seated, soleus H-reflex excitability was decreased after training in many AIS C and D subjects. Changes in reflex excitability coincided with changes in stimulation intensities at H-threshold, 50% maximal H-reflex, and at maximal H-reflex, while an interaction between leg side and AIS scale for the H-reflex slope was also found. Adaptations of the intrinsic properties of soleus motoneurons and Ia afferents, the excitability profile of the soleus motoneuron pool, oligosynaptic inputs, and corticospinal inputs may all contribute to these changes. The findings of this study demonstrate that locomotor training impacts the amplitude of the monosynaptic motoneuron responses based on the demands of the motor task in people with chronic SCI.

Locomotor training alters the behavior of flexor reflexes during walking in human spinal cord injury

In humans, a chronic spinal cord injury (SCI) impairs the excitability of pathways mediating early flexor reflexes and increases the excitability of late, long-lasting flexor reflexes. We hypothesized that in individuals with SCI, locomotor training will alter the behavior of these spinally mediated reflexes. Nine individuals who had either chronic clinically motor complete or incomplete SCI received an average of 44 locomotor training sessions. Flexor reflexes, elicited via sural nerve stimulation of the right or left leg, were recorded from the ipsilateral tibialis anterior (TA) muscle before and after body weight support (BWS)-assisted treadmill training. The modulation pattern of the ipsilateral TA responses following innocuous stimulation of the right foot was also recorded in 10 healthy subjects while they stepped at 25% BWS to investigate whether body unloading during walking affects the behavior of these responses. Healthy subjects did not receive treadmill training. We observed a phase-dependent modulation of early TA flexor reflexes in healthy subjects with reduced body weight during walking. The early TA flexor reflexes were increased at heel contact, progressively decreased during the stance phase, and then increased throughout the swing phase. In individuals with SCI, locomotor training induced the reappearance of early TA flexor reflexes and changed the amplitude of late TA flexor reflexes during walking. Both early and late TA flexor reflexes were modulated in a phase-dependent pattern after training. These new findings support the adaptive capability of the injured nervous system to return to a prelesion excitability and integration state.

Transpinal and transcortical stimulation alter corticospinal excitability and increase spinal output

The objective of this study was to assess changes in corticospinal excitability and spinal output following noninvasive transpinal and transcortical stimulation in humans. The size of the motor evoked potentials (MEPs), induced by transcranial magnetic stimulation (TMS) and recorded from the right plantar flexor and extensor muscles, was assessed following transcutaneous electric stimulation of the spine (tsESS) over the thoracolumbar region at conditioning-test (C-T) intervals that ranged from negative 50 to positive 50 ms. The size of the transpinal evoked potentials (TEPs), induced by tsESS and recorded from the right and left plantar flexor and extensor muscles, was assessed following TMS over the left primary motor cortex at 0.7 and at 1.1× MEP resting threshold at C-T intervals that ranged from negative 50 to positive 50 ms. The recruitment curves of MEPs and TEPs had a similar shape, and statistically significant differences between the sigmoid function parameters of MEPs and TEPs were not found. Anodal tsESS resulted in early MEP depression followed by long-latency MEP facilitation of both ankle plantar flexors and extensors. TEPs of ankle plantar flexors and extensors were increased regardless TMS intensity level. Subthreshold and suprathreshold TMS induced short-latency TEP facilitation that was larger in the TEPs ipsilateral to TMS. Noninvasive transpinal stimulation affected ipsilateral and contralateral actions of corticospinal neurons, while corticocortical and corticospinal descending volleys increased TEPs in both limbs. Transpinal and transcortical stimulation is a noninvasive neuromodulation method that alters corticospinal excitability and increases motor output of multiple spinal segments in humans.

Locomotor training improves premotoneuronal control after chronic spinal cord injury

Spinal inhibition is significantly reduced after spinal cord injury (SCI) in humans. In this work, we examined if locomotor training can improve spinal inhibition exerted at a presynaptic level. Sixteen people with chronic SCI received an average of 45 training sessions, 5 days/wk, 1 h/day. The soleus H-reflex depression in response to low-frequency stimulation, presynaptic inhibition of soleus Ia afferent terminals following stimulation of the common peroneal nerve, and bilateral EMG recovery patterns were assessed before and after locomotor training. The soleus H reflexes evoked at 1.0, 0.33, 0.20, 0.14, and 0.11 Hz were normalized to the H reflex evoked at 0.09 Hz. Conditioned H reflexes were normalized to the associated unconditioned H reflex evoked with subjects seated, while during stepping both H reflexes were normalized to the maximal M wave evoked after the test H reflex at each bin of the step cycle. Locomotor training potentiated homosynaptic depression in all participants regardless the type of the SCI. Presynaptic facilitation of soleus Ia afferents remained unaltered in motor complete SCI patients. In motor incomplete SCIs, locomotor training either reduced presynaptic facilitation or replaced presynaptic facilitation with presynaptic inhibition at rest. During stepping, presynaptic inhibition was modulated in a phase-dependent manner. Locomotor training changed the amplitude of locomotor EMG excitability, promoted intralimb and interlimb coordination, and altered cocontraction between knee and ankle antagonistic muscles differently in the more impaired leg compared with the less impaired leg. The results provide strong evidence that locomotor training improves premotoneuronal control after SCI in humans at rest and during walking.

Cervicothoracic multisegmental transpinal evoked potentials in humans

The objectives of this study were to establish the neurophysiological properties of the transpinal evoked potentials (TEPs) following transcutaneous electric stimulation of the spine (tsESS) over the cervicothoracic region, changes in the amplitude of the TEPs preceded by median nerve stimulation at group I threshold, and the effects of tsESS on the flexor carpi radialis (FCR) H-reflex in thirteen healthy human subjects while seated. Two re-usable self-adhering electrodes, connected to function as one electrode (cathode), were placed bilaterally on the clavicles. A re-usable electrode (anode) was placed on the cervicothoracic region covering from Cervical 4 – Thoracic 2 and held under constant pressure throughout the experiment. TEPs were recorded bilaterally from major arm muscles with subjects seated at stimulation frequencies of 1.0, 0.5, 0.33, 0.2, 0.125, and 0.1 Hz, and upon double tsESS pulses delivered at an inter-stimulus interval of 40 ms. TEPs from the arm muscles were also recorded following median nerve stimulation at the conditioning-test (C-T) intervals of 2, 3, 5, 8, and 10 ms. The FCR H-reflex was evoked and recorded according to conventional methods following double median nerve pulses at 40 ms, and was also conditioned by tsESS at C-T intervals that ranged from −10 to +50 ms. The arm TEPs amplitude was not decreased at low-stimulation frequencies and upon double tsESS pulses in all but one subject. Ipsilateral and contralateral arm TEPs were facilitated following ipsilateral median nerve stimulation, while the FCR H-reflex was depressed by double pulses and following tsESS at short and long C-T intervals. Non-invasive transpinal stimulation can be used as a therapeutic modality to decrease spinal reflex hyper-excitability in neurological disorders and when combined with peripheral nerve stimulation to potentiate spinal output.

Neurophysiological characterization of transpinal evoked potentials in human leg muscles

The objectives of this study were to characterize the neurophysiological properties of the compound muscle action potentials (CMAPs) evoked by transcutaneous electric stimulation of the spine (tsESS), and the effects of tsESS on the soleus H-reflex in seated and standing healthy human subjects. In seated semi-prone subjects with the trunk semi-flexed, two re-usable self-adhering electrodes (cathode), connected to act as one electrode, were placed bilaterally on the iliac crests. A re-usable pregelled electrode (anode) was placed on the thoracolumbar region at thoracic 10-lumbar 1 and held under constant pressure throughout the experiment. CMAPs were recorded bilaterally from ankle muscles with subjects seated semi-prone at 1.0, 0.3, 0.2, 0.125, and 0.1 Hz following tsESS. The soleus H-reflex, evoked by posterior tibial nerve stimulation via conventional methods, was measured following tsESS at inter-stimulus intervals (ISIs) that ranged from -100 to 100 ms with the subjects seated semi-prone and during standing. The tsESS-induced CMAPs were not decreased at low stimulation frequencies, and the soleus H-reflex excitability was profoundly decreased by tsESS at ISIs that ranged from -5 to 20 ms with the subjects seated semi-prone and during standing. CMAPs induced by tsESS may be utilized to assess spinal-to-muscle conduction time while bypassing spinal motoneuron excitability and tsESS can be used as a modality to decrease spinal reflex hyper-excitability in neurological disorders.

Effects of mechanical vibration of the foot sole and ankle tendons on cutaneomuscular responses in man

The modulation of cutaneomuscular responses in response to mechanical vibration applied to the foot sole and to the ankle tendons was established in ten healthy subjects. The effects of mechanical vibration applied to the skin adjacent to the tibialis anterior (TA) and Achilles tendons were examined in two subjects. With the subjects seated, mechanical vibration applied to the TA and/or Achilles tendons significantly depressed the cutaneomuscular responses in all subjects, regardless of the frequency (50, 150, 250 Hz) of vibration. Mechanical vibration applied either to the foot sole or to the skin adjacent to the tendons induced no significant effects. The demonstration that mechanical vibration applied to muscle tendons exerts an inhibitory effect on cutaneomuscular responses supports the hypothesis that receptors that mediate body kinesthesia can be used as a vehicle to alter the spinal excitability state. The data suggests that tendon vibration could be utilized in neurological disorders to induce exogenous-mediated potentiation of presynaptic inhibition.

Functional reorganization of soleus H-reflex modulation during stepping after robotic-assisted step training in people with complete and incomplete spinal cord injury

Body weight-supported (BWS) robotic-assisted step training on a motorized treadmill is utilized with the aim to improve walking ability in people after damage to the spinal cord. However, the potential for reorganization of the injured human spinal neuronal circuitry with this intervention is not known. The objectives of this study were to determine changes in the soleus H-reflex modulation pattern and activation profiles of leg muscles during stepping after BWS robotic-assisted step training in people with chronic spinal cord injury (SCI). Fourteen people who had chronic clinically complete, motor complete, and motor incomplete SCI received an average of 45 training sessions, 5 days per week, 1 h per day. The soleus H-reflex was evoked and recorded via conventional methods at similar BWS levels and treadmill speeds before and after training. After BWS robotic-assisted step training, the soleus H-reflex was depressed at late stance, stance-to-swing transition, and swing phase initiation, allowing a smooth transition from stance to swing. The soleus H-reflex remained depressed at early and mid-swing phases of the step cycle promoting a reciprocal activation of ankle flexors and extensors. The spinal reflex circuitry reorganization was, however, more complex, with the soleus H-reflex from the right leg being modulated either in a similar or in an opposite manner to that observed in the left leg at a given phase of the step cycle after training. Last, BWS robotic-assisted step training changed the amplitude and onset of muscle activity during stepping, decreased the step duration, and improved the gait speed. BWS robotic-assisted step training reorganized spinal locomotor neuronal networks promoting a functional amplitude modulation of the soleus H-reflex and thus step progression. These findings support that spinal neuronal networks of persons with clinically complete, motor complete, or motor incomplete SCI have the potential to undergo an endogenous-mediated reorganization, and improve spinal reflex function and walking function with BWS robotic-assisted step training.

Neurophysiological characteristics of human leg muscle action potentials evoked by transcutaneous magnetic stimulation of the spine

The objectives of this study were to establish the neurophysiological properties of the compound muscle action potentials (CMAPs) evoked by transcutaneous magnetic stimulation of the spine (tsMSS) and the effects of tsMSS on the soleus H-reflex. In semi-prone seated subjects with trunk semi-flexed, the epicenter of a figure-of-eight magnetic coil was placed at Thoracic 10 with the handle on the midline of the vertebral column. The magnetic stimulator was triggered by monophasic single pulses of 1 ms, and the intensity ranged from 90% to 100% of the stimulator output across subjects. CMAPs were recorded bilaterally from ankle and knee muscles at the interstimulus intervals of 1, 3, 5, 8, and 10 s. The CMAPs evoked were also conditioned by posterior tibial and common peroneal nerve stimulation at a conditioning-test (C-T) interval of 50 ms. The soleus H-reflex was conditioned by tsMSS at the C-T intervals of 50, 20, -20, and -50 ms. The amplitude of the CMAPs was not decreased when evoked at low stimulation frequencies, excitation of group I afferents from mixed peripheral nerves in the leg affected the CMAPs in a non-somatotopical neural organization pattern, and tsMSS depressed soleus H-reflex excitability. These CMAPs are likely due to orthodromic excitation of nerve motor fibers and antidromic depolarization of different types of afferents. The latency of these CMAPs may be utilized to establish the spine-to-muscle conduction time in central and peripheral nervous system disorders in humans. tsMSS may constitute a non-invasive modality to decrease spinal reflex hyperexcitability and treat hypertonia in neurological disorders.

Modulation of reciprocal and presynaptic inhibition during robotic-assisted stepping in humans

OBJECTIVE

To establish the modulation pattern of reciprocal inhibition and presynaptic inhibition of soleus Ia afferents during robot-assisted stepping in healthy subjects.

METHODS

During stepping, the soleus H-reflex was conditioned by percutaneous stimulation of the ipsilateral common peroneal nerve with a single pulse at stimulation intensities that ranged from 0.9 to 1.2 TA M-wave motor thresholds across subjects. To control for movement of recording and stimulating electrodes, a supramaximal stimulus 80ms after the conditioned and/or unconditioned H-reflexes was delivered to the posterior tibial nerve. The short (2, 3, 4ms) and long (60-80ms) conditioning-test intervals at which the largest amount of reflex depression was observed with the subjects seated were utilized during stepping. Stimuli were randomly dispersed across the step cycle which was divided into 16 equal bins.

RESULTS

Reciprocal inhibition exerted from flexor group I afferents onto soleus motoneurons was decreased at mid-stance and increased and late-stance and throughout the swing phase. Presynaptic inhibition of soleus Ia afferents was increased at heel strike and decreased at late-stance and early swing phases.

CONCLUSION

Reciprocal inhibition between ankle antagonistic muscles and presynaptic inhibition of soleus Ia afferents are modulated in a similar pattern to that reported during walking on a treadmill with full weight bearing and without robot-assisted leg movement.

SIGNIFICANCE

The activity of spinal interneuronal circuits engaged in patterned locomotor activity supports a reciprocal gait pattern during robot-assisted stepping in healthy humans.

Reduced reciprocal inhibition during assisted stepping in human spinal cord injury

The aim of this study was to establish the modulation pattern of the reciprocal inhibition exerted from tibialis anterior (TA) group I afferents onto soleus motoneurons during body weight support (BWS) assisted stepping in people with spinal cord injury (SCI). During assisted stepping, the soleus H-reflex was conditioned by percutaneous stimulation of the ipsilateral common peroneal nerve at one fold TA M-wave motor threshold with a single pulse delivered at a short conditioning-test interval. To counteract movement of recording and stimulating electrodes, a supramaximal stimulus at 80-100 ms after the test H-reflex was delivered. Stimuli were randomly dispersed across the step cycle which was divided into 16 equal bins. The conditioned soleus H-reflex was significantly facilitated throughout the stance phase, while during swing no significant changes on the conditioned H-reflex were observed when compared to the unconditioned soleus H-reflex recorded during stepping. Spontaneous clonic activity in triceps surae muscle occurred in multiple phases of the step cycle at a mean frequency of 7 Hz for steps with and without stimulation. This suggests that electrical excitation of TA and soleus group Ia afferents did not contribute to manifestation of ankle clonus. Absent reciprocal inhibition is likely responsible for lack of soleus H-reflex depression in swing phase observed in these patients. The pronounced reduced reciprocal inhibition in stance phase may contribute to impaired levels of co-contraction of antagonistic ankle muscles. Based on these findings, we suggest that rehabilitation should selectively target to transform reciprocal facilitation to inhibition through computer controlled reflex conditioning protocols.

Plantar Cutaneous Afferents Normalize the Reflex Modulation Patterns During Stepping in Chronic Human Spinal Cord Injury

Plantar cutaneous afferent transmission is critical for recovery of locomotion in spinalized animals, whereas a phase-dependent reflex modulation is apparent during fictive or real locomotion. In nine people with a chronic spinal cord injury (SCI) the effects of foot sole stimulation on the soleus H-reflex and tibialis anterior (TA) flexion reflex modulation patterns during assisted stepping were established on different days. The soleus H-reflex was elicited by posterior tibial nerve stimulation followed by a supramaximal stimulus 100 ms after the test H-reflex to control for movement of recording electrodes. The flexion reflex was evoked by sural nerve stimulation with a 30-ms pulse train, recorded from the ipsilateral TA muscle, and elicited at 1.2- to twofold the reflex threshold. During assisted stepping, spinal reflexes were conditioned by percutaneous stimulation of the ipsilateral metatarsals at threefold perceptual threshold with a 20-ms pulse train delivered at 9- to 11-ms conditioning-test intervals. Stimuli were randomly dispersed across the step cycle, which was divided into 16 equal bins. The conditioned soleus H-reflex was significantly facilitated at midstance and depressed during midswing when compared with the unconditioned soleus H-reflex recorded during stepping. Foot sole stimulation induced a significant facilitation of the long-latency TA flexion reflex before, during, and after stance-to-swing transition when compared with the unconditioned long-latency TA flexion reflex during stepping. This study provides evidence that plantar cutaneous afferents remarkably influence the soleus H-reflex and TA flexion reflex modulation patterns during stepping and support that actions of plantar cutaneous afferents onto spinal interneuronal circuits engaged in locomotion are manifested in a phase-dependent manner in chronic SCI subjects.

Soleus H-reflex gain, threshold, and amplitude as function of body posture and load in spinal cord intact and injured subjects

In this study, we established parameters of the soleus H-reflex excitability in response to changes of posture and load in 8 chronic spinal cord injured (SCI) and 10 spinal-intact subjects. The soleus H-reflex recruitment curve was established in all subjects while they were supine, seated, and standing on a stable treadmill. During standing, body weight support (BWS) was provided via an upper body harness and ranged in SCI subjects from 20%-50% and in spinal-intact subjects was set at 0% and 50%. Stimuli corresponding to the H-threshold (H(th)), maximal H-reflex amplitude (H(max)), and 50% of H(max) as well as the reflex gain were estimated based on a sigmoid function of the ascending limb of the soleus H-reflex recruitment curve. The soleus H-reflex gain, H(max) amplitude, and stimuli corresponding to H(th), 50% of H(max), and H(max) were increased in SCI subjects regardless of the body position and loading. Further, the reflex gain was not modulated appropriately during conditions of weight bearing in SCI subjects. Impaired spinal reflex excitability in SCI subjects is accompanied by changes of the H-reflex recruitment curve parameters regardless of presence or absence of body loading.

On the methods employed to record and measure the human soleus H-reflex

The aim of this study was to investigate if the magnitude of the soleus H-reflex is different depending on the method employed to measure its size (peak-to-peak amplitude vs. area). In this study, 13 healthy human subjects participated, while the soleus H-reflex was induced via conventional methods. In the first experiment, the soleus H-reflex was recorded via two monopolar electrodes and was evoked at least at eight different stimulation intensities in respect to the recovery curve of the H-reflex and at three different inter-stimulus intervals (ISIs) (8, 5, and 2 s). The ISI refers to the time delay between the single pulses delivered to the posterior tibial nerve within a single trial. In the second experiment, the effects of common peroneal nerve (CPN) stimulation at short (2-4 ms) and at long (60-120 ms) conditioning test (C-T) intervals on the soleus H-reflex elicited every 5 s were established. Control and conditioned reflexes were recorded via a single differential bipolar electrode. In both experiments, H-reflexes were quantified by measuring their size as peak-to-peak amplitude and as area under the full-wave rectified waveform. The reflex responses recorded through two monopolar electrodes across stimulation intensities and ISIs measured as peak-to-peak amplitude had larger values than measured as area. In contrast, the magnitude of the reflexes, conditioned by CPN stimulation at either short or long C-T intervals and recorded via a single differential electrode, were not significantly different when measured as peak-to-peak amplitude or as area. Our findings indicate that monopolar recordings yield different reflex sizes depending on the method employed to measure the reflex size, and that the H-reflex measured as area might detect better the homosynaptic reflex depression. The lack of observing such differences with bipolar recordings might be related to changes of the reflex shape at a given stimulus intensity due to inhibitory inputs. The implications of our findings are discussed in respect to human reflex studies.

The H-reflex as a probe: pathways and pitfalls

The Hoffmann (or H) reflex is considered a major probe for non-invasive study of sensorimotor integration and plasticity of the central nervous system in humans. The first section of this paper reviews the neurophysiological properties of the H-reflex, which if ignored create serious pitfalls in human experimental studies. The second section reviews the spinal inhibitory circuits and neuronal pathways that can be indirectly assessed in humans using the H-reflex. The most confounding factor is that reciprocal, presynaptic, and Ib inhibition do not act in isolation during movement. Therefore, characterization of these spinal circuits should be more comprehensive, especially in cases of a neurological injury because neurophysiological findings are critical for the development of successful rehabilitation protocols. To conclude, the H-reflex is a highly sensitive reflex with an amplitude that is the result of complex neural mechanisms that act synchronously. If these limitations are recognized and addressed, the H-reflex constitutes one of the major probes to assess excitability of interneuronal circuits at rest and during movement in humans.