EMGLAB: objective outcome measures in neurophysiological testing.

The aim of this work was to objectively measure and quantify the results of various neurophysiological tests and indirectly provide objective outcome measures for neurological therapy and rehabilitation. We have studied the silence of Electromyographic (EMG) activity after evoking motor potentials with magnetic cortical stimulation. Since different criteria were previously used to determine the level where the silence of muscle activity ends, an objective computer aided method was developed. This analysis was further developed to include objective testing of surface EMG, long latency reflexes, reciprocal inhibition of the H-reflex, H-reflex recovery curve and decrement testing. Responses were recorded at different sampling frequencies, depending on the application, time window, filter settings, etc. The developed software proved to be a fast and objective tool, able to standardize the determination of different neurophysiological tests, and as such a valuable tool facilitating multi-center studies and diminishing human bias. The software reduced the study time with each patient. Until date we have used the software with the Medtronic, Medelec and BTS EMG instruments.

Masked myoclonus in corticobasal degeneration: neurophysiological study of a case.

A single case study of a 58 year-old male with right asymmetric apraxia and akinetic-rigid syndrome is described. Brainimaging scans (MRI, SPECT) indicated asymmetric cortical atrophy compatible with the diagnosis of Corticobasal Degeneration. Reflex myoclonus was absent and myoclonic discharges only appeared in response to pharmacological treatment of limb dystonia and rigidity. Electromyographic evidence of jerky movements was recorded only in the affected right hand and forearm after muscle relaxation, and myoclonus was not preceded by an EEG paroxysm. The cortical components of the correspondent SEPs were not increased in amplitude while LLRs recordings showed a late response over the muscles of the affected side. Furthermore, the duration of post MEP silent period was bilaterally reduced. This single case study report points out that sometimes myoclonus in Corticobasal Degeneration can be masked by the presence of increased muscle tone.

Removal of organic pollutants from industrial wastewater by electrogenerated Fenton's reagent.

This study was performed to investigate the treatment of an industrial wastewater mainly containing naphthalene- and anthraquinone-sulphonic acids, by electrogenerated Fenton's reagent. The hydrogen peroxide was produced in situ by electrochemical reduction of oxygen on graphite-felt cathodes and the Fe2+ ions were also regenerated by cathodic reduction of Fe3+. The influence of cathode potential, Fe2+ concentration and electrode surface pre-treatment on chemical oxygen demand (COD) removal and colour fading were studied. Results indicated that the higher COD removal was obtained in the presence of 3 mM of ferrous ions working at a constant potential of -1 V vs. SCE. Moreover, it was shown that both chemical and electrochemical pre-treatments of the cathode surface resulted in a decrease of COD depletion.

Functional and clinical changes in upper limb spastic patients treated with botulinum toxin (BTX).

Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks. In order to study the usefulness of botulinum toxin type A (BTX) as a therapy for spasticity, we studied 15 patients affected by spasticity secondary to stroke. Tests included: clinical evaluation of tone (Ashworth scale); active angles of extension and flexion at elbow and wrist; Hmax/Mmax ratio from flexor carpi radialis (FCR); Hreflex presynaptic inhibition from FCR during vibration; Task score; and video recording. Patients were injected with BTX into one or more muscles with total doses not exceeding 200 International Units (IU). The tests were performed immediately prior to injection and repeated 2 weeks afterwards. Furthermore, in eight patients, testing was also performed one month after BTX injection. Between two weeks and one month after BTX there were no statistically significant differences. A statistically significant difference in the Task and Ashworth scores before and after treatment emerged (p < 0.0014), but only 6 patients showed a clear improvement in motor performance. Overall, we observed an improvement in the angle of active extension and flexion at the wrist and elbow. There were no significant changes in the Hmax/Mmax ratio and the Hreflex presynaptic inhibition during vibration. All the patients reported a subjective improvement. The results suggest that subjective benefits can be gained from the use of BTX in patients affected by spasticity, and that the degree of motor improvement seems to depend on the motor recovery obtained before treatment.

Transcranial magnetic stimulation and silent period in spasmodic torticollis.

OBJECTIVE: Our objective was to study the corticobulbar projections to neck muscles in cervical dystonia. DESIGN: We compared both the motor evoked potentials and the electromyographic silent period after transcranial magnetic stimulation from sternocleidomastoid and trapezius muscles in a group of 13 patients with spasmodic torticollis with those of 20 healthy volunteers. RESULTS: With the target muscle at rest, no changes of motor threshold, motor evoked potentials latency, and amplitude were observed in dystonic patients. With facilitation, the mean amplitude of the motor evoked potentials was increased in patients compared with controls, the significant difference being for the trapezius muscle, whereas the latency did not differ between groups. The cortical silent period was significantly shorter in dystonic patients than in healthy subjects in both muscles. The duration of the cortical silent period recorded from the sternocleidomastoid muscle showed a positive correlation with the degree of neurologic disability assessed by Tsui's scale. No abnormalities of both nerve conduction velocity and peripheral silent period by stimulation of accessory nerve were found. CONCLUSIONS: These results indicate an impairment of the mechanisms of inhibitory motor control in patients with spasmodic torticollis, which could be the result of a decrease of the basal ganglia inhibitory output over the motor cortex.

Differences between the time constant of sensory and motor peripheral nerve fibers: further studies and considerations.

Using a method of latent addition, we previously demonstrated that sensory fibers had time constants that were about three times longer than those of motor fibers. The aim of the present work was to confirm this difference by determining the time constants for single sensory axons by using microneurography and for single motor axons by recording single motor units with bipolar concentric needle electrodes. To determine the influence of the conditioning pulse on the neural time constant, we used both depolarizing and hyperpolarizing conditioning pulses. When hyperpolarizing conditioning pulses at comparable intensity were applied, the tendency was to find shorter time constants than when depolarizing pulses were applied, although still with the motor time constant being slightly shorter. Although the absolute values varied with the different methods, the sensory time constant was generally three times the motor time constant for depolarizing conditioning stimuli, whereas for hyperpolarizing conditioning stimuli the difference dropped to about one and a half. These characteristics improve understanding of the behavior of sensory and motor axons, and, in particular, explain the differential excitability. Determination of neural time constants might prove valuable for clinical use.

Hypokalemic thyrotoxic paralysis: a rare cause of tetraparesis with acute onset in Europeans.

We describe a 21-year-old Italian male affected by hypokalemic tetraparesis with acute onset. In the emergency ward, the patient was agitated, with tachycardia (140/min) and systolic hypertension (180/70 mm Hg). He was not able to flex the lower extremities against a light resistance and furthermore, he was hypotonic and without tendon reflexes. One hour later he developed strength deficit of the upper extremities as well. Biochemical analyses revealed severe hypopotassemia (2.1 meg/l). After administration of 140 meq potassium phosphate, the patient began to improve, and 12 h after the onset he was able to walk normally. Successive investigations documented an undiagnosed case of Graves' disease. Thyrotoxic hypokalemic paralysis has been observed almost only in Asians, however, with this case and others reported, we believe that it should be considered as a cause of muscular paralysis also in Caucasians.

Computer-aided determination of the silent period.

Silence of electromyographic (EMG) activity after an evoked muscle twitch has been studied extensively. However, different criteria have been used to determine the level at which the silence of muscle activity ends, and the purpose of this work was to develop an objective method able to determine the silent period even when data were acquired using different EMG instruments. The silent period evoked by transcranial magnetic stimulation was determined bilaterally from abductor pollicis brevis (APB) muscles in 11 subjects, from trapezius muscles in 9 subjects, and from sternocleidomastoid muscles in 11 subjects. All subjects were healthy controls and gave their informed consent to participate in the study. Muscle activity was recorded via surface electrodes. Recordings from 10 stimuli were rectified, averaged, and plotted logarithmically by dividing the mean of the prestimulus EMG activity into the whole trace. Plotted in this way, the one-level represents the mean rectified EMG amplitude of the prestimulus activity. The end of the silent period was measured automatically as the moment at which Student's t test was no longer significantly different, when testing the window of mean prestimulus EMG activity with respect to a 4-ms window centered around the assumed end of the silent period (resolution 0.1 ms). The mean silent periods were 183.7 +/- 49.8 ms for APB, 194.2 +/- 28.8 ms for trapezius, and 194.8 +/- 73.6 ms for sternocleidomastoid muscles, measured from the M-response latency (mean latency: APB 19.7 +/- 1.9 ms, trapezius 7.8 +/- 0.6 ms, and sternocleidomastoid 6.7 +/- 0.8 ms). Computer-aided measurement proved to be a fast and objective tool able to standardize determination of the silent period.

A volume-conduction analysis of magnetic stimulation of peripheral nerves.

Magnetic stimulation is a method to study several nervous disorders as well as the intact nervous system in humans. Interest in magnetic stimulation of peripheral nerves has grown rapidly, but difficulties in locating the site of excitation have prevented it from becoming a routine clinical tool. It has been reasoned that the activating function of long and straight nerves is the first spatial derivative of the electric field component parallel to the nerves. Therefore, to predict the site of activation, one has to compute this field feature. We describe here an analytical mathematical model and investigate the influence of volume-conductor shape on the induced field. Predictions of the site of activation are given for typical stimulation coil arrangements and these results are compared with experimental and literature data. Comparisons suggest that the activating function is not simply the spatial gradient of the induced electric field, but that other mechanisms are also involved. The model can be easily utilized in the search for more efficient coil constructions and improved placements with respect to the target nerves.

Transverse-field activation mechanism in magnetic stimulation of peripheral nerves.

The activating function of peripheral nerves in magnetic stimulation is thought to be the gradient of the induced electric field component parallel to the nerve. This implies that there are several orientations of the coil that should not excite nerves. We show that these orientations, however, often yield high-amplitude and even supramaximal muscle response, indicating that the model of the activating function has to be modified. We propose that the electric field component perpendicular to the nerve is responsible for these unexpected muscle responses. Our conclusion is based on practical experiments with different coils and on computer simulations of the induced electric field and its gradient.

H-reflex recovery curve and reciprocal inhibition of H-reflex of the upper limbs in patients with spasticity secondary to stroke.

The H-reflex recovery curve of the lower limb is considered a useful test for the diagnosis of spasticity, and recently the reciprocal inhibition of the H-reflex has proven to be abnormal in patients affected with spasticity. We studied the H-reflex recovery curve and the reciprocal inhibition of the H-reflex in the upper limb of a group of 33 patients with different degrees of spasticity secondary to stroke. Results were compared with those of 25 controls. The aim of this study was to investigate if the two tests showed any direct correlation with the degree of spasticity and, furthermore, with other clinical measures that are present in patients with spasticity as part of an upper motoneuron syndrome (i.e., changes in muscle tone, reflexes, force, etc.). The results showed an abnormality of both tests in most patients (decrease of the three phases of inhibition in the reciprocal inhibition test and increase of the late facilitation part of the H-reflex recovery curve), and these abnormalities seem mostly to be related to muscle tone, most important being the degree of correlation between tone and changes in abnormality of the H-reflex recovery curve (P < 0.03).

The time constants of motor and sensory peripheral nerve fibers measured with the method of latent addition.

The time constants of motor and sensory fibers in the human ulnar, median and tibial nerves were determined using the method of latent addition. Two square-wave stimuli were applied: the first one was subthreshold and the second, at various delays relative to the first, was adjusted to achieve threshold activation. Strength-delay curves were obtained, from which the time constant was determined using a mathematical model. Sensory fibers had time constants that were about 3 times the time constant for motor fibers. The strength-delay curves gave similar time constants as those obtained from strength-duration curves.

Principles of digital sampling of a physiologic signal.

The practice of clinical neurophysiology requires fast, reliable and accurate assessment of a variety of biologic signals. Appropriate filters and rates of analog-to-digital sampling must be used to avoid distorting the signal. Using principles of sampling theory and examples, we describe the frequency content of signals encountered in clinical neurophysiology laboratories, offer guidelines for band-limiting frequencies, and give rules for determining minimal sampling frequencies. Errors introduced by undersampling (aliasing) are illustrated. When sophisticated computational techniques, such as discrete Fourier transform, are used to reconstruct the original wave form, a sampling frequency just above the double of the highest frequency content of the signal is adequate. Sampling neurophysiologic wave forms for direct display, however, requires a sampling frequency at least 4 times as high as that of the upper frequency filter.

Outline of the "map of the major active faults in the Holocene" netween the Po and Piave rivers and lake Como (Northern Italy)

This study consists in the compilation of a "Map of the major active faults in the Holocene" (last 10 4 years)between the Po and Piave rivers and lake Como and in a Catalogue of the faults that appear on the map. Besides the various faults (numbered, classified as "active" and "supposed active" and subdivided into "outcropping" and "buried"), the Map also shows folds (anticlines and synclines), areal movements (uplifting, lowering and tilting), and epicenters of earthquakes with Richter's magnitude >=6. The Catalogue contains a description of the fault characteristics (type of fault, attitude, displacement, main historical earthquakes, period of activity, classification etc..), which are summarized on special data sheets. Overall, 32 faults have been included on the Map and in the Catalogue. Of these, 9 are "active" faults and 23 are "supposed active faults"; they are concentrated prevalently in the Veneto Pre-Alps and Belluno sector, where several folds also proved to be "active", and in the Lessini M.ts-L. Garda sector. As far as areal movement is concerned, it is possible to distinguish five areas differing in the type of movement. As regards earthquakes, only four seismic events in the study area had characteristics comparable to earthquakes with magnitudes <=6. The detailed analysis of the hypocentral depths of all the earthquakes recorded instrumentally in the study area since 1982, revealed depths of less than 30 km.(AU)

Determining the site of stimulation during magnetic stimulation of a peripheral nerve.

Magnetic stimulation has not been routinely used for studies of peripheral nerve conduction primarily because of uncertainty about the location of the stimulation site. We performed several experiments to locate the site of nerve stimulation. Uniform latency shifts, similar to those that can be obtained during electrical stimulation, were observed when a magnetic coil was moved along the median nerve in the region of the elbow, thereby ensuring that the properties of the nerve and surrounding volume conductor were uniform. By evoking muscle responses both electrically and magnetically and matching their latencies, amplitudes and shapes, the site of stimulation was determined to be 3.0 +/- 0.5 cm from the center of an 8-shaped coil toward the coil handle. When the polarity of the current was reversed by rotating the coil, the latency of the evoked response shifted by 0.65 +/- 0.05 msec, which implies that the site of stimulation was displaced 4.1 +/- 0.5 cm. Additional evidence of cathode- and anode-like behavior during magnetic stimulation comes from observations of preferential activation of motor responses over H-reflexes with stimulation of a distal site, and of preferential activation of H-reflexes over motor responses with stimulation of a proximal site. Analogous behavior is observed with electrical stimulation. These experiments were motivated by, and are qualitatively consistent with, a mathematical model of magnetic stimulation of an axon.

Relevance of stimulus duration for activation of motor and sensory fibers: implications for the study of H-reflexes and magnetic stimulation.

Electric stimuli with durations of 0.5-1.0 msec are optimal for studies of H-reflexes. It is more difficult to obtain H-reflexes with shorter duration stimuli or with magnetic stimulation. In order to understand this behavior, we studied the excitation thresholds for motor and sensory fibers in the ulnar, median and tibial nerves using both electric and magnetic stimulation. For short duration electrical stimuli (0.1 msec) the threshold for motor fibers is lower than for sensory fibers. For longer duration electric stimuli (1.0 msec) the threshold for sensory fibers is lower. For magnetic stimulation the threshold for motor fibers is much lower than for sensory fibers. Thus, stimulus duration is a critical parameter for sensory fiber excitation, and current magnetic stimulators are not optimal.

Optimal focal transcranial magnetic activation of the human motor cortex: effects of coil orientation, shape of the induced current pulse, and stimulus intensity.

We studied the effects of coil orientation, stimulus intensity, and shape of the induced current pulse on the amplitudes of motor evoked potentials in the left abductor pollicis brevis of 10 normal adults who had transcranial magnetic stimulation. The optimal direction of currents induced in the brain is approximately perpendicular to the central sulcus, flowing diagonally from back to front. The most effective coil orientation depends on the shape of the induced current pulse and, when the first and second phases of the pulse are of similar size, also on the intensity of stimulation. Optimal mapping of the human motor cortex with magnetic stimulation requires knowledge of the influences of all these factors.

Spinal cord inhibitory mechanisms in Parkinson's disease.

We studied two spinal cord inhibitory mechanisms, recurrent (Renshaw) inhibition and reciprocal inhibition, in seven patients with asymmetric Parkinson's disease in order to determine their contribution to the pathogenesis of rigidity. Recurrent inhibition, studied in the leg, did not differ from that found in normal subjects. All three periods of reciprocal inhibition, studied in the forearm, were present but reduced in magnitude compared with those observed in normal subjects. The arms, whether more symptomatic or less symptomatic, gave similar results. The diminution of all three periods of reciprocal inhibition is similar to the findings in patients with dystonia and is apparently indicative of an abnormal supraspinal influence on spinal mechanisms in these two disorders of basal ganglia function.

[Diagnosis and treatment of myasthenia gravis: study of an inpatient population]. / Diagnóstico y tratamiento de la myasthenia gravis: estudio de una población hospitalaria.

Between 1974 and 1987 we have examined 50 patients with the diagnosis of myasthenia gravis. Female preponderance (2.5: 1) was found. Also, it was observed that most of the patients were aged between 20 and 49 years. Beside the clinical examination, the following tests were performed: (1) edrofonium test, (2) supramaximal repetitive nerve stimulation, (3) serum acetylcholine antibodies titers and (4) intraperitoneal passive transference of patient's sera to mice and recording of meepp's amplitude in the phrenic-diaphragm preparation in vitro. These four tests gave positive values for myasthenia in 90 to 100% of the cases. Thymus radiological examination was carried out by pneumomediastinography, which proved to correlate with the histological picture of the gland, and computed tomography, which disclosed some discrepances with the histology. Treatment was based on anticholinesterase drugs, corticosteroids and thymectomy, being the corticosteroids the most valuable therapeutical tool. Nine patients treated with steroids disclosed transitory worsening of their signs and symptoms at very early stages after onset of corticosteroid therapy, 6 of them had a disfavorable course in their follow-up. This observation seem to have value in the early prognosis of the disease.