[Interactive driving simulation--a new approach to diagnosis and rehabilitation of driving skills]. / Interaktive Fahrsimulation--ein neuer Weg zur Diagnose und Rehabilitation der Fahrtauglichkeit.

Until recently, major methodological problems were faced in the assessment and rehabilitation of driving ability in neurological patients, concerning practical driving lessons and driving tests as well as neuropsychological tests and therapies. The use of highly-advanced driving simulators may solve parts of this problem. However, a basic requirement for effective rehabilitation is the patients' acceptance of this method. In a semi-standardized interview with 56 patients we found that the driving simulator recently installed in the Neurological Rehabilitation Centre "Godeshöhe" was rated mainly positively. Also, patients experienced the simulator to be motivating, effective and informative. Hence, a very important prerequisite for successful use of driving simulators in neurological rehabilitation is given.

Reorganization of motor output in the non-affected hemisphere after stroke.

Motor evoked responses to focal transcranial magnetic stimulation were investigated over the unaffected hemisphere in 15 patients with hemiparesis after ischaemic stroke and compared with data from normal control subjects. Whereas responses to muscles ipsilateral to the stimulated hemisphere could only be elicited at maximal intensities in two out of 12 normal control subjects, such ipsilateral responses were recorded after stimulation of the unaffected hemisphere in patients with poor recovery after stroke at significantly lower thresholds, but not in patients with good recovery. These responses occurred with a somewhat longer (on average 6 ms) latency than the typical contralateral response. The duration of the silent period ipsilateral to stimulation of the unaffected hemisphere was longer than in control subjects. Also the contralateral threshold for the unaffected hemisphere was elevated in comparison with the control group. In one patient, who developed mirror movements after stroke, the ipsilateral threshold was exceptionally low and the latency of the ipsilateral response identical to that seen contralaterally. It is concluded that the motor outputs in the unaffected hemisphere are significantly changed after stroke, including the unmasking of ipsilateral corticospinal projections. However, these pathways seem to be of little significance for recovery, as the existence of these responses was not correlated with clinical improvement. The unaffected hemisphere after stroke shows plastic changes in motor output organization after a contralateral lesion.

Delay in simple reaction time after focal transcranial magnetic stimulation of the human brain occurs at the final motor output stage.

It is known that the execution of the motor response in a simple reaction time (RT) task can be delayed by transcranial magnetic stimulation (TMS). This paper is aimed at determining the site of action where the delay in RT occurs. A delay in RT was obtained only at those TMS sites over the motor cortex contralateral to the responding hand, which produced also a muscle twitch in the responding hand. The delay in RT covaried with the TMS intensity and increased the closer the time of TMS approached the expected time of reaction onset. Visual and auditory go-signals yielded similar delays in RT, but only when TMS was applied about 40 ms later for the visual go-signal, corresponding to the modality specific difference in RT control values. TMS of the supplementary motor area (SMA) immediately prior to the expected time of reaction onset produced no delay in RT. Spinal excitability as tested by F waves showed a pre-movement facilitation in the control trials which continued seemingly undisturbed during the period of RT delay after TMS. It can be concluded that the delay in RT is not due to SMA stimulation or spinal inhibition but depends on effective stimulation of neural elements in the motor cortex which are active very late in the process of movement release from the final motor output stage.

Hemispheric asymmetry of transcallosal inhibition in man.

The transcallosal connecting fibres linking corresponding projection areas of the same muscles of the right and left primary motor cortex may play an important role in control of unilateral movements. It appears that they have mainly inhibitory effects. This was further evaluated by transcranial magnetic stimulation using two focal coils placed on the optimal positions, i.e. the positions with the lowest thresholds at the motor representation areas of the first dorsal interosseous muscle of the left and right sides. A conditioning stimulus was given to one hemisphere 10 ms prior to the test stimulus at the opposite hemisphere. The inhibition was evaluated as relative amplitude reduction. Eleven normal right-handed subjects and 11 normal left-handed subjects participated in this study. Handedness was evaluated by the Oldfield inventory. It was found that in right-handers the inhibition after stimulation of the "dominant" left hemisphere was more marked than after stimulation of the "non-dominant" right hemisphere. In contrast, the group of left-handed subjects showed inhomogeneous findings with either right- or left-side predominant inhibition. It is concluded that not handedness but hemispheric dominance contributes to the laterality of inhibition. The results point to a superior role of the language-dominant hemisphere in governing inter-hemispheric control of motor cortical connections, supporting the view that the "language-dominant" hemisphere is also "motor dominant".

Contactless impedance measurement by magnetic induction--a possible method for investigation of brain impedance.

Using a primary coil that induces eddy currents in a volume conductor, and a pair of secondary coils configured to form a differential transformer, it is possible to measure the conductivity of a volume conductor by the magnetic fields of the induced eddy currents. This method is especially favourable for measuring impedance of the brain, as the low conductance of the surrounding skull interferes only very slightly with the measuring process. In a simulation experiment a life-size skull model was filled with NaCl solutions of different concentrations in each half, so as to model the impedances of a normal and an oedematous hemisphere. The impedance differences could be clearly detected by a coil system of 25 mm diameter.

Spinal and supraspinal mechanisms contribute to the silent period in the contracting soleus muscle after transcranial magnetic stimulation of human motor cortex.

In the voluntarily activated muscle, transcranial magnetic stimulation (TMS) of motor cortex produces subsequently to the motor evoked potential (MEP) a silent period (SP) in the electromyogram. We studied the time course of soleus motoneuron (MN) pool excitability after conditioning TMS by Hoffmann reflex (HR) testing, to determine whether inaccessibility of MNs after corticospinal input contributes to the SP. Coincidently with the early part of the SP, and only in the contracting soleus, MN depression was obtained that covaried with the degree of preinnervation, and with the size of the preceding MN discharge. However, MN excitability recovered significantly prior to the end of the SP. It is concluded that in the contracting soleus spinal mechanisms (most likely Renshaw inhibition and MN afterhyperpolarization) contribute to the early part of the SP, while the late part of the SP is supraspinal (probably cortical) in origin.

Intact conduction of fastest corticospinal efferents is not sufficient for normal voluntary muscle strength: transcranial motor cortex stimulation in patients with tetraplegia.

In six patients with chronic severe tetraparesis, caused by closed head injury (3 cases), basilar thrombosis (2 cases) or global hypoxia (1 case), responses of suprathreshold transcranial magnetic stimulation of motor cortex to thenar and abductor hallucis muscles on both sides were studied. Results showed in most patients normal thresholds and latencies (17 out of 24 latencies within normal +/- 2 S.D., 20 thresholds within normal +/- 1 S.D.) and amplitudes of even higher than normal values. Latencies or thresholds did not correlate with severity of pareses and were in marked contrast to the severe pareses of the muscles under investigation. Despite different etiology CT-scans showed diffuse atrophy of cerebral white matter as a common finding. It is concluded that intact descending corticospinal motor pathways are a necessary but not a sufficient condition for voluntary motor function.

Transcranial stimulation of motor cortex in upper motor neurone syndrome: its relation to the motor deficit.

The purpose of this investigation was to clarify the functional significance of the fastest cortico-motoneuronal connections in chronic upper motor neurone syndromes. Using magneto-electrical stimulation of motor cortex the intactness of cortico-motoneuronal connections was assessed in 51 patients presenting with variable degrees of impairment. There was a gross correlation between clinical impairment of the patient and the degree of pathology of cortico-motoneuronal efferents. Covariation of clinical data with transcranial stimulation was better than covariation with the size of lesion on CT scans. In some patients, however, definite clinical impairment, especially affecting distal fractionated movements, was associated with completely normal responses. There was no evidence of response abnormality in distal muscles ipsilateral to the hemispheric lesion. The data indicate that motor deficit can exist in the presence of normal cortico-motoneuronal conduction times, showing that intactness of these connections is not a sufficient condition for preservation of voluntary motor activities. This underlines the importance of other pathways for the pathogenesis of upper motor neurone syndromes.

The opiate antagonist naloxone does not arouse man from natural delta sleep.

To see if the opiate receptor/endorphin system plays a part in the regulation of natural sleep in humans the effects of the opiate antagonist naloxone on delta sleep were examined. The sleep behaviour of each of six healthy male volunteers aged 20-32 years was monitored by continuous recordings of EEG, EOG, EMG, heart rate and respiratory rate for 3 nights. The sleep stages were evaluated according to Rechtschaffen and Kales. Naloxone (0.03 mg/kg body wt.) or saline as placebo was administered intravenously in a double-blind randomized order during the spontaneously occurring delta sleep, the effects being observed on sleep behaviour and recorded variables. Naloxone never elicited arousal, either in the EEG or in the subjects' behaviour. The only effect noted was an increase in the mean latency of the first REM sleep stage. Naloxone does not arouse humans from natural delta sleep. It seems unlikely therefore, that endorphins play a role in the regulation of delta sleep in humans unless there are opiate receptor subtypes involved for which naloxone has a low affinity in man.

Cerebral potentials during skilled slow positioning movements.

Movement-related potentials recorded from the scalp of man were investigated in two skilled positioning tasks, requiring flexions at different joints of the upper extremities. The average response time was approximately 1 sec. Subjects paced their movements themselves and performed without visual control or other external cues. After each trial a delayed visual feedback was given. It was found that the negative potential shift prior to the EMG onset, the 'Bereitschaftpotential', is followed by a persisting negativity during the execution of the action until the target position is reached. Approximately at this point a positive-going deflection appears. This 'goal-directed movement potential' is composed of at least two components: (a) a widely distributed, centrally dominant negativity, and (b) a smaller negative wave over the sensorimotor cortex contralateral to the responding limb. Small variations in response force do not influence the amplitude of the potentials. A negative shift in anticipation of the visual feedback has a topography different from the movement-related potentials, being predominant over the right hemisphere independent of the hand used

Cerebral potentials during smooth goal-directed hand movements in right-handed and left-handed subjects.

During smooth goal-directed hand movements a negative potential shift can be recorded from the human scalp. This goal-directed movement potential (GDMP) is preponderant over central areas with a maximum at the vertex and, over the motor cortex, contralaterally larger than ipsilaterally to the moving hand. In 11 right-handed and 6 left-handed subjects, the morphology and distribution of these potential shifts were studied in relation to task differences, moving hand and handedness. The results show a functional differentiation of two components of the GDMP: (1), a lateralized, slow negative wave, restricted to the precentral area and selectively varying with the hand used, and (2), a widespread, bilateral symmetrical component, selectively influenced by task-specific and individual factors. Two effects reflect an influence of the subject's handedness on the GDMP: (A) averaged for both hand conditions, there are larger amplitudes over the hemisphere contralateral to the dominant hand, and (b), averaged for both hemispheres, larger amplitudes result from using the non-dominant hand.

Relationships between the late component of the contingent negative variation and the bereitschaftspotential.

The purpose of this study was to determine whether the late component of the contingent negative variation (CNV) in a S1-S2-respond paradigm shares critical features with the Bereitschaftspotential (BP) prior to self-paced voluntary movements. In a group of 8 subjects, the late CNV and the BP exhibited: (a) similar effects of response speed variation, (b) corresponding influences of subjective factors, and (c) a similar scalp distribution with the exception that the BP was much more lateralized. In contrast, no such relationships were found between early CNV and BP.

Late components of average evoked potentials in children with different abilities to concentrate.

Three matched groups, each of seven 11-year-old children with good, average and poor ability to concentrate were selected. Evoked potentials and EEG alpha amplitude changes after visual imperative stimuli were studied in warned reaction time experiments. The children with poor ability to concentrate (compared with the other groups) showed longer latencies of the P2 component and reduced amplitudes of the P2-N2 deflection at the vertex. Similar, although attenuated, effects were found in the Fz derivation. No group effects could be established for Oz. These findings are discussed in relation to group differences in pre-stimulus negativity and alpha attenuation, as reported in a previous paper.

Contingent negative variation and alpha attenuation responses in children with different abilities to concentrate.

In three paralleled groups, each of seven children (age, 11 years) with reliable high, average and low ability to concentrate, measured by psychological tests, the contingent negative variation (CNV) and the concomitant alpha attenuation responses were studied in warned reaction time experiments. Stimuli were tone (S1) and patterned light (S2). In half of the trials, S2 was a square, in the other half a triagle, stimuli being projected in random order onto the fixation point. In two experiments the children had to react (a) to each type of S2, and (b) selectively to one type of S2. Significant group differences were found. In comparison to the children with low ability to concentrate, the children with average and especially those with high ability to concentrate showed: (1) stronger central occipital alpha attenuation responses to the warning stimulus, but no differences in the early CNVs; (2) more occipital alpha reduction and enhanced development of central negativity before the imperative stimulus; (3) task-specific modulation of these responses, i.e. larger pre-S2 rise in negativity in the simple reaction task, and stronger pre-S2 reduction of alpha amplitudes in the discriminative reaction task.