Effect of fatiguing maximal voluntary contraction on excitatory and inhibitory responses elicited by transcranial magnetic motor cortex stimulation

The role of clinical neurophysiology in the definition and assessment of fatigue and fatigability

Though a common symptom, fatigue is difficult to define and investigate, occurs in a wide variety of neurological and systemic disorders, with differing pathological causes. It is also often accompanied by a psychological component. As a symptom of long-term COVID-19 it has gained more attention. In this review, we begin by differentiating fatigue, a perception, from fatigability, quantifiable through biomarkers. Central and peripheral nervous system and muscle disorders associated with these are summarised. We provide a comprehensive and objective framework to help identify potential causes of fatigue and fatigability in a given disease condition. It also considers the effectiveness of neurophysiological tests as objective biomarkers for its assessment. Among these, twitch interpolation, motor cortex stimulation, electroencephalography and magnetencephalography, and readiness potentials will be described for the assessment of central fatigability, and surface and needle electromyography (EMG), single fibre EMG and nerve conduction studies for the assessment of peripheral fatigability. The purpose of this review is to guide clinicians in how to approach fatigue, and fatigability, and to suggest that neurophysiological tests may allow an understanding of their origin and interactions. In this way, their differing types and origins, and hence their possible differing treatments, may also be defined more clearly.

Increased corticospinal inhibition following brief maximal and submaximal contractions in humans

A potentiating conditioning contraction (CC) has been shown to increase silent period duration, an index of corticospinal inhibition; however, it is unknown if the CC must induce potentiation for corticospinal inhibition to increase. Ten healthy, young adults (four females) completed this study to assess potentiation and silent period (SP) duration before and after four types of CCs: voluntary and electrically evoked maximal CCs to optimize potentiation, and voluntary and electrically evoked submaximal CCs (∼40% of maximal voluntary force) that induced minimal potentiation. Stimulation was applied to the ulnar nerve to evoke twitches for the assessment of potentiation and to evoke tetanic CCs of the first dorsal interosseous muscle. The SP was elicited by applying transcranial magnetic stimulation to the motor cortex during brief contractions at 25% of maximal voluntary force. Changes to twitch force and SP duration were not different for voluntary and tetanic contractions, so data were pooled. Twitch force increased by 81.2 ± 35.7% (P < 0.001) and 3.2 ± 6.5% (P = 0.039) following maximal and submaximal CCs, respectively. The SP was prolonged following maximal (12.6 ± 6.3%; P < 0.001) and submaximal (4.8 ± 4.9%; P < 0.001) CCs. Correlations between post-CC twitch force and SP duration were not significant for maximal or submaximal conditions (r = -0.068; r = 0.067; P ≥ 0.780, respectively). Duration of the SP increased not only following maximal-intensity CCs but also after submaximal-intensity CCs that induced virtually no potentiation (∼3%). Thus, we suggest that corticospinal inhibition is not directly related to mechanisms of muscle potentiation per se, but, rather, the level of muscle contraction likely mediates feedback from large diameter afferents that affect the SP.NEW & NOTEWORTHY The transcranial magnetic stimulation-induced silent period reflects a transient state of corticospinal inhibition that is influenced by recent history of muscle activation, which may include an effect of potentiation. We demonstrate that silent period duration increases following both voluntary and electrically evoked maximal and submaximal conditioning contractions, even though the latter intensity produced virtually no muscle potentiation. Feedback from group Ia and Ib muscle afferents is proposed as the cause of the increased corticospinal inhibition.

Transcranial Magnetic Stimulation as a Tool to Investigate Motor Cortex Excitability in Sport

Transcranial magnetic stimulation, since its introduction in 1985, has brought important innovations to the study of cortical excitability as it is a non-invasive method and, therefore, can be used both in healthy and sick subjects. Since the introduction of this cortical stimulation technique, it has been possible to deepen the neurophysiological aspects of motor activation and control. In this narrative review, we want to provide a brief overview regarding TMS as a tool to investigate changes in cortex excitability in athletes and highlight how this tool can be used to investigate the acute and chronic responses of the motor cortex in sport science. The parameters that could be used for the evaluation of cortical excitability and the relative relationship with motor coordination and muscle fatigue, will be also analyzed. Repetitive physical training is generally considered as a principal strategy for acquiring a motor skill, and this process can elicit cortical motor representational changes referred to as use-dependent plasticity. In training settings, physical practice combined with the observation of target movements can enhance cortical excitability and facilitate the process of learning. The data to date suggest that TMS is a valid technique to investigate the changes in motor cortex excitability in trained and untrained subjects. Recently, interest in the possible ergogenic effect of non-invasive brain stimulation in sport is growing and therefore in the future it could be useful to conduct new experiments to evaluate the impact on learning and motor performance of these techniques.

Gerta Vrbová, a guide and a friend for a generation of neuro-myologists - Her scientific legacies and relations with colleagues

Gerta Sidonová - Vrbová, (Trnava, Slovakia, November 28, 1926 - London, UK, October 2, 2020) has been a key neuroscientist, who for almost half a century has contributed important findings and hypotheses on the relationships between motoneurons and skeletal muscle fibers, in particular on the differentiation and extent of plasticity of the peculiar characteristics of the different types of fibers present in mammalian muscles. This issue, Ejtm 31 (1), 2021, opens with the personal obituary authored by Dirk Pette, who remember his lifelong collaboration with Gerta, describing the many molecular and metabolic events that occur by changing the pattern of activation of adult muscle fibers through neuromuscular low frequency electrical stimulation. To honor the many scientific legacies of Gerta Vrbová and her impact on a generation of researchers studying myology and managements of neuromuscular disorders I add here additional examples of Gerta's scientific heritage and of her relations with colleagues.

Gerta Vrbová, a guide and a friend for a generation of neuro-myologists – Her scientific legacies and relations with colleagues

Gerta Sidonová - Vrbová, (Trnava, Slovakia, November 28, 1926 - London, UK, October 2, 2020) has been a key neuroscientist, who for almost half a century has contributed important findings and hypotheses on the relationships between motoneurons and skeletal muscle fibers, in particular on the differentiation and extent of plasticity of the peculiar characteristics of the different types of fibers present in mammalian muscles. This issue, Ejtm 31 (1), 2021, opens with the personal obituary authored by Dirk Pette, who remember his lifelong collaboration with Gerta, describing the many molecular and metabolic events that occur by changing the pattern of activation of adult muscle fibers through neuromuscular low frequency electrical stimulation. To honor the many scientific legacies of Gerta Vrbová and her impact on a generation of researchers studying myology and managements of neuromuscular disorders I add here additional examples of Gerta’s scientific heritage and of her relations with colleagues.

Neuropsychological and neurophysiological correlates of fatigue in post-acute patients with neurological manifestations of COVID-19: Insights into a challenging symptom

More than half of patients who recover from COVID-19 experience fatigue. We studied fatigue using neuropsychological and neurophysiological investigations in post-COVID-19 patients and healthy subjects. Neuropsychological assessment included: Fatigue Severity Scale (FSS), Fatigue Rating Scale, Beck Depression Inventory, Apathy Evaluation Scale, cognitive tests, and computerized tasks. Neurophysiological examination was assessed before (PRE) and 2 min after (POST) a 1-min fatiguing isometric pinching task and included: maximum compound muscle action potential (CMAP) amplitude in first dorsal interosseous muscle (FDI) following ulnar nerve stimulation, resting motor threshold, motor evoked potential (MEP) amplitude and silent period (SP) duration in right FDI following transcranial magnetic stimulation of the left motor cortex. Maximum pinch strength was measured. Perceived exertion was assessed with the Borg-Category-Ratio scale. Patients manifested fatigue, apathy, executive deficits, impaired cognitive control, and reduction in global cognition. Perceived exertion was higher in patients. CMAP and MEP were smaller in patients both PRE and POST. CMAP did not change in either group from PRE to POST, while MEP amplitudes declined in controls POST. SP duration did not differ between groups PRE, increased in controls but decreased in patients POST. Patients' change of SP duration from PRE to POST was negatively correlated to FSS. Abnormal SP shortening and lack of MEP depression concur with a reduction in post-exhaustion corticomotor inhibition, suggesting a possible GABA_B-ergic dysfunction. This impairment might be related to the neuropsychological alterations. COVID-19-associated inflammation might lead to GABAergic impairment, possibly representing the basis of fatigue and explaining apathy and executive deficits.

TMS-induced silent periods: A review of methods and call for consistency

Transcranial magnetic stimulation (TMS)-induced silent periods provide an in vivo measure of human motor cortical inhibitory function. Cortical silent periods (cSP, also sometimes referred to as contralateral silent periods) and ipsilateral silent periods (iSP) may change with advancing age and disease and can provide insight into cortical control of the motor system. The majority of past silent period work has implemented largely varying methodology, sometimes including subjective analyses and incomplete methods descriptions. This limits reproducibility of silent period work and hampers comparisons of silent period measures across studies. Here, we discuss methodological differences in past silent period work, highlighting how these choices affect silent period outcome measures. We also outline challenges and possible solutions for measuring silent periods in the unique case of the lower limbs. Finally, we provide comprehensive recommendations for collection, analysis, and reporting of future silent period studies.

Supraspinal fatigue in human inspiratory muscles with repeated sustained maximal efforts

To investigate the involvement of supraspinal fatigue in the loss of maximal inspiratory pressure (Pi_max), we fatigued the inspiratory muscles. Six participants performed 5 sustained maximal isometric inspiratory efforts (15-s contractions, duty cycle ∼75%) which reduced Pi_max, as measured from esophageal and mouth pressure, to around half of their initial maximums. Transcranial magnetic stimulation (TMS) delivered over the motor cortex near the beginning and end of each maximal effort evoked superimposed twitch-like increments in the ongoing Pi_max, increasing from ∼1.0% of Pi_max in the unfatigued contractions to ≥40% of ongoing Pi_max for esophageal and mouth pressures. The rate of increase in the superimposed twitch as Pi_max decreased with fatigue was not significantly different between the esophageal and mouth pressure measures. The inverse relationship between superimposed twitch pressure and Pi_max indicates a progressive decline in the ability of motor cortical output to drive the inspiratory muscles maximally, leading to the development of supraspinal fatigue. TMS also evoked silent periods in the electromyographic recordings of diaphragm, scalenes, and parasternal intercostal. The duration of the silent period increased with fatigue in all three muscles, which suggests greater intracortical inhibition, with the largest change observed in the diaphragm. The peak rate of relaxation in pressure during the silent period slowed as fatigue developed, indicating peripheral contractile changes in the active inspiratory muscles. These changes in the markers of fatigue show that both central and peripheral fatigue contribute to the loss in Pi_max when inspiratory muscles are fatigued with repeated sustained maximal efforts.NEW & NOTEWORTHY When the inspiratory muscles are fatigued with repeated sustained maximal efforts, supraspinal fatigue, a component of central fatigue, contributes to the loss in maximal inspiratory pressure. The presence of supraspinal fatigue was confirmed by the increase in amplitude of twitch-like increments in pressure evoked by motor cortical stimulation during maximal efforts, indicating that motor cortical output was not maximal as extra muscle force could be generated to increase inspiratory pressure.

On task: Considerations and future directions for studies of corticospinal excitability in exercise neuroscience and related disciplines

Over the last few decades, transcranial magnetic stimulation (TMS) has emerged as a conventional laboratory technique in human neurophysiological research. Exercise neuroscientists have used TMS to study central nervous system contributions to fatigue, training, and performance in health, injury, and disease. In such studies, corticospinal excitability is often assessed at rest or during simple isometric tasks with the implication that the results may be extrapolated to more functional and complex movement outside of the laboratory. However, the neural mechanisms that influence corticospinal excitability are both state- and task-dependent. Furthermore, there are many sites of modulation along the pathway from the motor cortex to the muscle; a fact that is somewhat obscured by the all-encompassing and poorly defined term “corticospinal excitability”. Therefore, the tasks we use to assess corticospinal excitability and the conclusions that we draw from such a global measure of the motor pathway must be taken into consideration. The overall objective of this review is to highlight the task-dependent nature of corticospinal excitability and the tools used to assess modulation at cortical and spinal sites of modulation. By weighing the advantages and constraints of conventional approaches to studying corticospinal excitability, and considering some new and novel approaches, we will continue to advance our understanding of the neural control of movement during exercise.

Functional brain anatomy of exercise regulation

Knowledge about possible brain mechanisms involved in the regulation of exercise intensity has vastly grown over the last decade. The current review attempts to condense this knowledge currently published with a focus on brain imaging studies. A number of psychological manipulations known to influence exercise intensity are discussed with respect to their possibly underlying brain structures. Although far from forming a complete picture, current knowledge allows to speculate on various possible influences and their corresponding neural bases. Especially, the roles of the insular cortex, anterior cingulate cortex, basal ganglia and prefrontal cortex structures are discussed. Interoceptive signals processed in the insular cortex can influence motor activity likely via anterior cingulate cortex with themselves being influenced by higher order prefrontal cortical regions (e.g., when mediating expectancy effects). Such higher order prefrontal regions can also modulate motivation and thus motor activity by influencing valuation processes in the midbrain and other structures.

Modulation of specific inhibitory networks in fatigued locomotor muscles of healthy males

Reduced maximal force capability of skeletal muscle, as a consequence of exercise, can be due to peripheral or central fatigue mechanisms. In upper-limb muscles, neuromuscular fatigue is concurrent with reduced corticospinal excitability and increased inhibition (lengthened corticospinal silent period [CSP]; reduced short-interval intracortical inhibition [SICI] ratio). However, it is unclear whether these adjustments occur in response to fatiguing exercise of locomotor muscles. This study examined the effect of fatiguing, maximal, knee-extensor exercise on motor cortical excitability and inhibition. Thirteen males performed three 30-s maximal, isometric contractions with the dominant knee-extensors (MVC1, MVC2 and MVC3), separated by 60 s. At the end of, and between each MVC, neuromuscular fatigue, corticospinal excitability, CSP and SICI were assessed with supramaximal stimulation of the femoral nerve, and motor cortical stimulation, respectively. Repeated MVCs caused progressive reductions in MVC (- 10, - 24 and - 29%, respectively, P ≤ 0.01), along with significant peripheral (reductions in potentiated twitch of - 23, -53 and - 60%, respectively, P < 0.001) and central (reductions in VA of - 10% and - 13% post-MVC2 and 3, respectively, P ≤ 0.01) fatigue. Following MVC1 corticospinal excitability was reduced, and remained depressed thereafter. CSP increased in duration and remained longer throughout the protocol; whereas, no change in SICI was observed. Repeated, sustained, maximal contractions of the knee-extensors elicited substantial peripheral and central fatigue that was accompanied by a concomitant reduction in corticospinal excitability. However, divergent responses exist between inhibitory networks within the motor cortex, the activity of inhibitory networks mediated by GABA_B are increased, whereas those mediated by GABA_A are not.

Effects of fatigue on corticospinal excitability of the human knee extensors

NEW FINDINGS

What is the central question of this study? Do group III and IV muscle afferents act at the spinal or cortical level to affect the ability of the central nervous system to drive quadriceps muscles during fatiguing exercise? What is the main finding and its importance? The excitability of the motoneurone pool of vastus lateralis was unchanged by feedback from group III and IV muscle afferents. In contrast, feedback from these afferents may contribute to inhibition at the cortex. However, the excitability of the corticospinal pathway was not directly affected by feedback from these afferents. These findings are important for understanding neural processes during fatiguing exercise. In upper limb muscles, changes in afferent feedback, motoneurone excitability, and motor cortical output can contribute to failure of the central nervous system to recruit muscles fully during fatigue. It is not known whether similar changes occur with fatigue of muscles in the lower limb. We assessed the corticospinal pathway to vastus lateralis during fatiguing sustained maximal voluntary contractions (MVCs) of the knee extensors and during firing of fatigue-sensitive group III/IV muscle afferents maintained by postexercise ischaemia after fatiguing MVCs of the knee extensors and, separately, the flexors. In two experiments, subjects (n = 9) performed brief knee extensor MVCs before and after 2-min sustained MVCs of the knee extensors (experiment 1) or knee flexors (experiment 2). During MVCs, motor evoked potentials (MEPs) were elicited by transcranial magnetic stimulation over the motor cortex and thoracic motor evoked potentials (TMEPs) by electrical stimulation over the thoracic spine. During the 2-min extensor contraction, the size of vastus lateralis MEPs normalized to the maximal M-wave increased (P < 0.05), but normalized TMEPs were unchanged (P = 0.16). After the 2-min MVC, maintained firing of group III/IV muscle afferents had no effect on vastus lateralis MEPs or TMEPs (P = 0.18 and P = 0.50, respectively). Likewise, after the 2-min knee flexor MVC, maintained firing of these afferents showed no effect on vastus lateralis MEPs or TMEPs (P = 0.69 and P = 0.34, respectively). Motoneurones of vastus lateralis do not become less excitable during fatiguing isometric MVCs. Moreover, fatigue-sensitive group III/IV muscle afferents fail to affect the overall excitability of vastus lateralis motoneurones during MVCs.

Relationship between blood lactate and cortical excitability between taekwondo athletes and non-athletes after hand-grip exercise

OBJECTIVES

In taekwondo competitions, fatigue has a large influence on performance. Recent studies have reported that the excitability in the primary hand motor cortex, investigated with transcranial magnetic stimulation (TMS), is enhanced at the end of a maximal exercise and that this improvement correlates with blood lactate. The aim of the present study was to investigate the relationship between blood lactate and cortical excitability in taekwondo athletes and non-athletes.

METHODS

The excitability of the primary motor cortex was measured before and after fatiguing hand-grip exercise by TMS. Capillary blood lactate was measured at rest (pre-test), at the end (0 min), and at 3 and 10 min after the exercise by using a "Lactate Pro" portable lactate analyzer.

RESULTS

Significant differences in cortical excitability between the two groups were found after the exercise (p < 0.05). Furthermore, we found a significant relationship between cortical excitability and blood lactate (p < 0.01).

CONCLUSION

The present findings showed changes in the excitability in the athletes group and also in the non-athletes group. However, blood lactate seems to have the greater effect in trained subjects compared to untrained subjects. In fact, it appears that, during extremely intensive exercise in taekwondo athletes, lactate may delay the onset of fatigue not only by maintaining the excitability of muscle, but also by increasing the excitability of the primary motor cortex more than in non-athletes.

Functional Assessment of Corticospinal System Excitability in Karate Athletes

Objectives

To investigate the involvement of the primary motor cortex (M1) in the coordination performance of karate athletes through transcranial magnetic stimulation (TMS).

Methods

Thirteen right-handed male karate athletes (25.0±5.0 years) and 13 matched non-athlete controls (26.7±6.2 years) were enrolled. A single-pulse TMS was applied using a figure-eight coil stimulator. Resting motor threshold (rMT) was determined. Surface electromyography was recorded from the first dorsal interosseous muscle. Motor evoked potential (MEP) latencies and amplitudes at rMT, 110%, and 120% of rMT were considered. Functional assessment of the coordination performance was assessed by in-phase (IP) and anti-phase (AP) homolateral hand and foot coordination tasks performed at 80, 120, and 180 bpm.

Results

Compared to controls, athletes showed lower rMT (p<0.01), shorter MEP latency (p<0.01) and higher MEP amplitude (p<0.01), with a significant correlation (r = 0.50, p<0.01) between rMT and MEP latency. Coordination decreased with increasing velocity, and better IP performances emerged compared to AP ones (p<0.001). In general, a high correlation between rMT and coordination tasks was found for both IP and AP conditions.

Conclusion

With respect to controls, karate athletes present a higher corticospinal excitability indicating the presence of an activity-dependent alteration in the balance and interactions between inhibitory and facilitatory circuits determining the final output from the M1. Furthermore, the high correlation between corticospinal excitability and coordination performance could support sport-specific neurophysiological arrangements.

Unilateral elbow flexion fatigue modulates corticospinal responsiveness in non-fatigued contralateral biceps brachii

Exercise-induced fatigue can change motor performance in non-exercised muscles. The objective was to investigate unilateral elbow flexion (EF) fatigue effects on the maximal voluntary force (MVC) and corticospinal excitability of contralateral non-exercised biceps brachii (BB). Transcranial magnetic, transmastoid electrical, and brachial plexus electrical stimulation were used to elicit motor evoked potentials (MEP), cervicomedullary motor evoked potentials (CMEP), and compound muscle action potentials in the contralateral non-exercised BB of 12 participants before and after (i) two bouts of 100-s unilateral EF (fatigue) or (ii) control. Three stimuli were evoked every 1.5 s during a series of 6-s isometric EF at 100%, 50%, and 5% of MVC. The non-exercised EF MVC force, electromyographic activity, and voluntary activation were not significantly different between fatigue and control. Non-exercised BB MEP and CMEP amplitudes during 100% MVCs demonstrated significantly higher (P = 0.03) and lower values (P = 0.01), respectively, after fatigue compared with control. There was no difference between the two conditions for MEP and CMEP amplitudes during 50% and 5% MVCs. Unilateral exercise-induced EF fatigue did not lead to cross-over central fatigue to the contralateral homologous muscle but enhanced the supraspinal responsiveness (MEP/CMEP) of the neural circuitries supplying central commands to non-exercised muscles at higher contraction intensity.

Neurophysiological Correlates of Central Fatigue in Healthy Subjects and Multiple Sclerosis Patients before and after Treatment with Amantadine

In ten healthy subjects and in ten patients suffering from Multiple Sclerosis (MS), we investigated the cortical functional changes induced by a standard fatiguing repetitive tapping task. The Cortical Silent Period (CSP), an intracortical, mainly GABA_B-mediated inhibitory phenomenon, was recorded by two different hand muscles, one acting as prime mover of the fatiguing index-thumb tapping task (First Dorsal Interosseous, FDI) and the other one not involved in the task but sharing largely overlapping central, spinal, and peripheral innervation (Abductor Digiti Minimi, ADM). At baseline, the CSP was shorter in patients than in controls. As fatigue developed, CSP changes involved both the “fatigued” FDI and the “unfatigued” ADM muscles, suggesting a cortical spread of central fatigue mechanisms. Chronic therapy with amantadine annulled differences in CSP duration between controls and patients, possibly through restoration of more physiological levels of intracortical inhibition in the motor cortex. These inhibitory changes correlated with the improvement of fatigue scales. The CSP may represent a suitable marker of neurophysiological mechanisms accounting for central fatigue generation either in controls or in MS patients, involving corticospinal neural pools supplying not only the fatigued muscle but also adjacent muscles sharing an overlapping cortical representation.

The effect of tonic contraction of the finger muscle on the motor cortical representation of the contracting adjacent muscle

This study examined the effect of tonic contraction of the finger muscle on the motor cortical representation of the contracting adjacent muscle. A representation map of the motor evoked potential (MEP) in the first dorsal interosseous (FDI) and abductor digiti minimi (ADM) muscles was obtained with the subject at rest or during tonic contraction of the ADM muscle while the FDI muscle was tonically contracted. The center of gravity (COG) of the MEP map in the FDI muscle shifted medially during contraction of the ADM muscle. Motor cortical excitability in the motor cortical representation of the FDI muscle that did not overlap with the motor cortical representation of the ADM muscle was suppressed, but motor cortical excitability in the motor cortical representation of the FDI muscle overlapping with the motor cortical representation of the ADM muscle was not suppressed during contraction of the ADM muscle. The motor cortical representation of the FDI muscle not overlapping with the motor cortical representation of the ADM muscle was located lateral to that of the FDI muscle that did overlap with the motor cortical representation of the ADM muscle. Medial shift of the COG of the motor cortical representation of the contracting finger muscle induced by tonic contraction of the adjacent finger muscle must be due to suppression of motor cortical excitability in the lateral part of the representation, which is not shared by the adjacent representation.

The effect of paired associative stimulation on fatigue resistance

Paired associative stimulation (PAS) is a non-invasive stimulation method developed to induce bidirectional changes in the excitability of the cortical projections to the target muscles. However, very few studies have shown an association between changes in motor evoked potentials (MEP) after PAS and behavioral changes in healthy subjects. In the present study we hypothesized that the functional relevance of PAS can be seen during fatiguing exercise, since there is always a central contribution to the development of fatigue. Transcranial magnetic stimulation was applied over the motor cortex to measure changes in the MEPs of the soleus muscle before and after PAS. Furthermore, fatigue resistance was tested during 15s sustained maximal isometric contractions before and after PAS. On average, fatigue resistance did not change after PAS, however the change in excitability correlated significantly with the change in fatigue resistance.

DISCUSSION

Functionality of PAS intervention was not demonstrated in this study. However, the observed relationship between excitability and fatigue resistance suggests that PAS might have affected central fatigue during short maximal contractions.

Descending motor pathways and cortical physiology after spinal cord injury assessed by transcranial magnetic stimulation: a systematic review

We performed here a systematic review of the studies using transcranial magnetic stimulation (TMS) as a research and clinical tool in patients with spinal cord injury (SCI). Motor evoked potentials (MEPs) elicited by TMS represent a highly accurate diagnostic test that can supplement clinical examination and neuroimaging findings in the assessment of SCI functional level. MEPs allows to monitor the changes in motor function and evaluate the effects of the different therapeutic approaches. Moreover, TMS represents a useful non-invasive approach for studying cortical physiology, and may be helpful in elucidating the pathophysiological mechanisms of brain reorganization after SCI. Measures of motor cortex reactivity, e.g., the short interval intracortical inhibition and the cortical silent period, seem to point to an increased cortical excitability. However, the results of TMS studies are sometimes contradictory or divergent, and should be replicated in a larger sample of subjects. Understanding the functional changes at brain level and defining their effects on clinical outcome is of crucial importance for development of evidence-based rehabilitation therapy. TMS techniques may help in identifying neurophysiological biomarkers that can reliably assess the extent of neural damage, elucidate the mechanisms of neural repair, predict clinical outcome, and identify therapeutic targets. Some researchers have begun to therapeutically use repetitive TMS (rTMS) in patients with SCI. Initial studies revealed that rTMS can induce acute and short duration beneficial effects especially on spasticity and neuropathic pain, but the evidence is to date still very preliminary and well-designed clinical trials are warranted. This article is part of a Special Issue entitled SI: Spinal cord injury.

Different corticospinal control between discrete and rhythmic movement of the ankle

We investigated differences in corticospinal and spinal control between discrete and rhythmic ankle movements. Motor evoked potentials (MEPs) in the tibialis anterior and soleus muscles and soleus H-reflex were elicited in the middle of the plantar flexion phase during discrete ankle movement or in the initial or later cycles of rhythmic ankle movement. The H-reflex was evoked at an intensity eliciting a small M-wave and MEPs were elicited at an intensity of 1.2 times the motor threshold of the soleus MEPs. Only trials in which background EMG level, ankle angle, and ankle velocity were similar among the movement conditions were included for data analysis. In addition, only trials with a similar M-wave were included for data analysis in the experiment evoking H-reflexes. Results showed that H reflex and MEP amplitudes in the soleus muscle during discrete movement were not significantly different from those during rhythmic movement. MEP amplitude in the tibialis anterior muscle during the later cycles of rhythmic movement was significantly larger than that during the initial cycle of the rhythmic movement or during discrete movement. Higher corticospinal excitability in the tibialis anterior muscle during the later cycles of rhythmic movement may reflect changes in corticospinal control from the initial cycle to the later cycles of rhythmic movement.

Sustained cycling exercise increases intracortical inhibition

PURPOSE

In the current study, we measured EMG suppression induced by subthreshold transcranial magnetic stimulation (TMS) to investigate the effects of sustained cycling exercise on intracortical inhibition.

METHODS

Sixteen subjects cycled at 75% of their maximum workload (Wmax) for 30 min, during which subthreshold TMS was applied at a defined crank angle where vastus lateralis (VL) EMG amplitude was increasing and approximately 50% of its recorded maximum. Subthreshold TMS was also applied during nonfatiguing control cycling bouts at 75% and 37.5% of Wmaxbefore sustained cycling.

RESULTS

Although EMG in VL during control cycling at 37.5% Wmax was approximately half that during cycling at 75% Wmax (P ≤ 0.05), the amount of EMG suppression was not different between workloads (P > 0.05). EMG amplitude in VL recorded in the last 5 min of sustained cycling was not different from the first 5 min (P > 0.05), whereas the amount of EMG suppression at the end of the sustained cycling was significantly greater than that at the start (P ≤ 0.05).

CONCLUSIONS

The increase in TMS-evoked EMG suppression during sustained cycling implies an increase in the excitability of the intracortical inhibitory interneurons during the exercise. The observed increase in intracortical inhibition is similar to that observed during sustained single joint contractions, suggesting that changes in the responsiveness of intracortical inhibitory interneurons are similar during locomotor exercise and static single joint contractions.

Increased probability of repetitive spinal motoneuron activation by transcranial magnetic stimulation after muscle fatigue in healthy subjects

Triple stimulation technique (TST) has previously shown that transcranial magnetic stimulation (TMS) fails to activate a proportion of spinal motoneurons (MNs) during motor fatigue. The depression in size of the TST response, but no attenuation of the conventional motor-evoked potential, suggested increased probability of repetitive spinal MN activation during exercise, even if some MNs failed to discharge by the brain stimulus. Here we used a modified TST [quadruple stimulation (QuadS) and quintuple stimulation (QuintS)] to examine the influence of fatiguing exercise on second and third MN discharges after a single TMS in healthy subjects. This method allows an estimation of the percentage of double and triple discharging MNs. Following a sustained contraction of the abductor digiti minimi muscle at 50% maximal force maintained to exhaustion, the size of QuadS and QuintS responses increased markedly, reflecting that a greater proportion of spinal MNs was activated two or three times by the transcranial stimulus. The size of QuadS responses did not return to precontraction levels during 10-min observation time, indicating long-lasting increase in excitatory input to spinal MNs. In addition, the postexercise behavior of QuadS responses was related to the duration of the contraction, pointing to a correlation between repeated activation of MNs and the subject's ability to maintain force. In conclusion, the study confirmed that an increased fraction of spinal MNs fire more than once in response to TMS when the muscle is fatigued. Repetitive MN firing may provide an adaptive mechanism to maintain motor unit activation and task performance during sustained voluntary activity.

Prior heat stress effects fatigue recovery of the elbow flexor muscles

INTRODUCTION

Long-lasting alterations in hormones, neurotransmitters, and stress proteins after hyperthermia may be responsible for the impairment in motor performance during muscle fatigue.

METHODS

Subjects (n = 25) performed a maximal intermittent fatigue task of elbow flexion after sitting in either 73° or 26°C to examine the effects of prior heat stress on fatigue mechanisms.

RESULTS

The heat stress increased the tympanic and rectal temperatures by 2.3° and 0.82°C, respectively, but there was full recovery prior to the fatigue task. Although prior heat stress had no effects on fatigue-related changes in volitional torque, electromyographic (EMG) activity, torque relaxation rate, motor evoked potential (MEP) size, and silent period (SP) duration, prior heat stress acutely increased the pre-fatigue relaxation rate and chronically prevented long-duration fatigue (P < 0.05).

CONCLUSIONS

These findings indicate that prior passive heat stress alone does not alter voluntary activation during fatigue, but prior heat stress and exercise produce longer-term protection against long-duration fatigue.

Behaviour of the motoneurone pool in a fatiguing submaximal contraction

During fatigue caused by a sustained maximal voluntary contraction (MVC), motoneurones become markedly less responsive when tested during the silent period following transcranial magnetic stimulation (TMS). To determine whether this reduction depends on the repetitive activation of the motoneurones, responses to TMS (motor evoked potentials, MEPs) and to cervicomedullary stimulation (cervicomedullary motor evoked potentials, CMEPs) were tested during a sustained submaximal contraction at a constant level of electromyographic activity (EMG). In such a contraction, some motoneurones are repetitively activated whereas others are not active. On four visits, eight subjects performed a 10 min maintained-EMG elbow flexor contraction of 25% maximum. Test stimuli were delivered with and without conditioning by TMS given 100 ms prior. Test responses were MEPs or CMEPs (two visits each, small responses evoked by weak stimuli on one visit and large responses on the other). During the sustained contraction, unconditioned CMEPs decreased ∼20% whereas conditioned CMEPs decreased ∼75 and 30% with weak and strong stimuli, respectively. Conditioned MEPs were reduced to the same extent as CMEPs of the same size. The data reveal a novel decrease in motoneurone excitability during a submaximal contraction if EMG is maintained. Further, the much greater reduction of conditioned than unconditioned CMEPs shows the critical influence of voluntary drive on motoneurone responsiveness. Strong test stimuli attenuate the reduction of conditioned CMEPs which indicates that low-threshold motoneurones active in the contraction are most affected. The equivalent reduction of conditioned MEPs and CMEPs suggests that, similar to findings with a sustained MVC, impaired motoneurone responsiveness rather than intracortical inhibition is responsible for the fatigue-related impairment of the MEP during a sustained submaximal contraction.

Spinal opioid receptor-sensitive muscle afferents contribute to the fatigue-induced increase in intracortical inhibition in healthy humans

We investigated the influence of spinal opioid receptor-sensitive muscle afferents on cortical changes following fatiguing unilateral knee-extensor exercise. On separate days, seven subjects performed an identical five sets of intermittent isometric right-quadriceps contractions, each consisting of eight submaximal contractions [63 ± 7% maximal voluntary contraction (MVC)] and one MVC. The exercise was performed following either lumbar interspinous saline injection or lumbar intrathecal fentanyl injection blocking the central projection of spinal opioid receptor-sensitive lower limb muscle afferents. To quantify exercise-induced peripheral fatigue, quadriceps twitch force (Q(tw,pot)) was assessed via supramaximal magnetic femoral nerve stimulation before and after exercise. Motor evoked potentials and cortical silent periods (CSPs) were evaluated via transcranial magnetic stimulation of the motor cortex during a 3% MVC pre-activation period immediately following exercise. End-exercise quadriceps fatigue was significant and similar in both conditions (Q(tw,pot) -35 and -39% for placebo and fentanyl, respectively; P = 0.38). Immediately following exercise on both days, motor evoked potentials were similar to those obtained prior to exercise. Compared with pre-exercise baseline, CSP in the placebo trial was 21 ± 5% longer postexercise (P < 0.01). In contrast, CSP following the fentanyl trial was not significantly prolonged compared with the pre-exercise baseline (6 ± 4%). Our findings suggest that the central effects of spinal opioid receptor-sensitive muscle afferents might facilitate the fatigue-induced increase in CSP. Furthermore, since the CSP is thought to reflect inhibitory intracortical interneuron activity, which may contribute to central fatigue, our findings imply that spinal opioid receptor-sensitive muscle afferents might influence central fatigue by facilitating intracortical inhibition.

Changes in presumed motor cortical activity during fatiguing muscle contraction in humans

AIM

Changes in sensory information from active muscles accompany fatiguing exercise and the force-generating capacity deteriorates. The central motor commands therefore must adjust depending on the task performed. Muscle potentials evoked by transcranial magnetic stimulation (TMS) change during the course of fatiguing muscle activity, which demonstrates activity changes in cortical or spinal networks during fatiguing exercise. Here, we investigate cortical mechanisms that are actively involved in driving the contracting muscles.

METHODS

During a sustained submaximal contraction (30% of maximal voluntary contraction) of the elbow flexor muscles we applied TMS over the motor cortex. At an intensity below motor threshold, TMS reduced the ongoing muscle activity in biceps brachii. This reduction appears as a suppression at short latency of the stimulus-triggered average of rectified electromyographic (EMG) activity. The magnitude of the suppression was evaluated relative to the mean EMG activity during the 50 ms prior to the cortical stimulus.

RESULTS

During the first 2 min of the fatiguing muscle contraction the suppression was 10 +/- 0.9% of the ongoing EMG activity. At 2 min prior to task failure the suppression had reached 16 +/- 2.1%. In control experiments without fatigue we did not find a similar increase in suppression with increasing levels of ongoing EMG activity.

CONCLUSION

Using a form of TMS which reduces cortical output to motor neurones (and disfacilitates them), this study suggests that neuromuscular fatigue increases this disfacilitatory effect. This finding is consistent with an increase in the excitability of inhibitory circuits controlling corticospinal output.

The response to paired motor cortical stimuli is abolished at a spinal level during human muscle fatigue

During maximal exercise, supraspinal fatigue contributes significantly to the decline in muscle performance but little is known about intracortical inhibition during such contractions. Long-interval inhibition is produced by a conditioning motor cortical stimulus delivered via transcranial magnetic stimulation (TMS) 50-200 ms prior to a second test stimulus. We aimed to delineate changes in this inhibition during a sustained maximal voluntary contraction (MVC). Eight subjects performed a 2 min MVC of elbow flexors. Single test and paired (conditioning-test interval of 100 ms) stimuli were delivered via TMS over the motor cortex every 7-8 s throughout the effort and during intermittent MVCs in the recovery period. To determine the role of spinal mechanisms, the protocol was repeated but the TMS test stimulus was replaced by cervicomedullary stimulation which activates the corticospinal tract. TMS motor evoked potentials (MEPs) and cervicomedullary motor evoked potentials (CMEPs) were recorded from biceps brachii. Unconditioned MEPs increased progressively with fatigue, whereas CMEPs increased initially but returned to the control value in the final 40 s of contraction. In contrast, both conditioned MEPs and CMEPs decreased rapidly with fatigue and were virtually abolished within 30 s. In recovery, unconditioned responses required <30 s but conditioned MEPs and CMEPs required 90 s to return to control levels. Thus, long-interval inhibition increased markedly as fatigue progressed. Contrary to expectations, subcortically evoked CMEPs were inhibited as much as MEPs. This new phenomenon was also observed in the first dorsal interosseous muscle. Tested with a high intensity conditioning stimulus during a fatiguing maximal effort, long-interval inhibition of MEPs was increased primarily by spinal rather than motor cortical mechanisms. The spinal mechanisms exposed here may contribute to the development of central fatigue in human muscles.

Locomotor exercise induces long-lasting impairments in the capacity of the human motor cortex to voluntarily activate knee extensor muscles

Muscle fatigue is a reduction in the capacity to exert force and may involve a "central" component originating in the brain and/or spinal cord. Here we examined whether supraspinal factors contribute to impaired central drive after locomotor endurance exercise. On 2 separate days, 10 moderately active individuals completed a locomotor cycling exercise session or a control session. Brief (2 s) and sustained (30 s) isometric knee extension contractions were completed before and after locomotor exercise consisting of eight, 5-min bouts of cycling at 80% of maximum workload. In the control session, subjects completed the isometric contractions in a rested state. Twitch responses to supramaximal motor nerve stimulation and transcranial magnetic stimulation were obtained to assess peripheral force-generating capacity and voluntary activation. Maximum voluntary contraction (MVC) force during brief contractions decreased by 23 +/- 6.3% after cycling exercise and remained 12 +/- 2.8% below baseline 45 min later (F(1,9) > 15.5; P < 0.01). Resting twitch amplitudes declined by approximately 45% (F(1,9) = 28.3; P < 0.001). Cortical voluntary activation declined from 90.6 +/- 1.6% at baseline to 80.6 +/- 2.1% after exercise (F(1,9) = 28.0; P < 0.001) and remained significantly reduced relative to control 30-45 min later (80.6 +/- 3.4%; F(1,9) = 10.7; P < 0.01). Thus locomotor exercise caused a long-lasting impairment in the capacity of the motor cortex to drive the knee extensors. Force was reduced more during sustained MVC after locomotor exercise than in the control session. Peripheral mechanisms contributed relatively more to this force reduction in the control session, whereas supraspinal fatigue played a greater role in sustained MVC reduction after locomotor exercise.

Unilateral grip fatigue reduces short interval intracortical inhibition in ipsilateral primary motor cortex

OBJECTIVE

This study was designed to examine whether exhaustive grip exercise of the left hand affected intracortical excitability in ipsilateral motor cortex.

METHODS

Ten healthy male subjects (aged 21-24 years) participated in experiment 1 in which paired-pulse transcranial magnetic stimulation (TMS) was used to test corticospinal and corticocortical excitability in right (relaxed) first dorsal interosseous (FDI) muscle during the recovery period after exhaustive forceful grip exercise of the left hand. Seven of the same subjects participated in experiment 2, in which the intensity of the test stimulus was adjusted so that the amplitude of motor evoked potential (MEP(TEST)) was kept constant throughout the measurement.

RESULTS

In experiment 1, MEP(TEST) was slightly reduced from 5 to 15min after exercise whilst short interval intracortical inhibition (SICI) at interstimulus interval (ISI) of 2 and 3ms became less effective. Intracortical facilitation (ICF) was unchanged. In experiment 2 when the MEP(TEST) was maintained at a constant size there was again no change in ICF, and the reduction in SICI was still present at the same intervals.

CONCLUSIONS

We conclude that unilateral exhaustive grip exercise reduced the excitability of the corticospinal output of the ipsilateral motor cortex whilst simultaneously reducing the excitability of SICI. These results would be compatible with the idea that fatigue increases the tonic level of interhemispheric inhibition from the fatigued to the non-fatigued cortex.

SIGNIFICANCE

Muscle fatigue to the point of exhaustion has lasting effects on the excitability of intracortical circuits in the non-exercised hemisphere, perhaps via changes in the tonic levels of activity in transcallosal pathways.

Contralateral muscle activity and fatigue in the human first dorsal interosseous muscle

During effortful unilateral contractions, muscle activation is not limited to the target muscles but activity is also observed in contralateral muscles. The amount of this associated activity is depressed in a fatigued muscle, even after correction for fatigue-related changes in maximal force. In the present experiments, we aimed to compare fatigue-related changes in associated activity vs. parameters that are used as markers for changes in central nervous system (CNS) excitability. Subjects performed brief maximal voluntary contractions (MVCs) with the index finger in abduction direction before and after fatiguing protocols. We followed changes in MVCs, associated activity, motor-evoked potentials (MEP; transcranial magnetic stimulation), maximal compound muscle potentials (M waves), and superimposed twitches (double pulse) for 20 min after the fatiguing protocols. During the fatiguing protocols, associated activity increased in contralateral muscles, whereas afterwards the associated force was reduced in the fatigued muscle. This force reduction was significantly larger than the decline in MVC. However, associated activity (force and electromyography) remained depressed for only 5–10 min, whereas the MVCs stayed depressed for over 20 min. These decreases were accompanied by a reduction in MEP, MVC electromyography activity, and voluntary activation in the fatigued muscle. According to these latter markers, the decrease in CNS motor excitability lasted much longer than the depression in associated activity. Differential effects of fatigue on (associated) submaximal vs. maximal contractions might contribute to these differences in postfatigue behavior. However, we cannot exclude differences in processes that are specific to either voluntary or to associated contractions.

Cortical and spinal modulation of antagonist coactivation during a submaximal fatiguing contraction in humans

This study investigates the control mechanisms at the cortical and spinal levels of antagonist coactivation during a submaximal fatiguing contraction of the elbow flexors at 50% of maximal voluntary contraction (MVC). We recorded motor-evoked potentials in the biceps brachii and triceps brachii muscles in response to magnetic stimulation of the motor cortex (MEP) and corticospinal tract (cervicomedullary motor-evoked potentials--CMEPs), as well as the Hoffmann reflex (H-reflex) and maximal M-wave (Mmax) elicited by electrical stimulation of the brachial plexus, before, during, and after the fatigue task. The results showed that although the coactivation ratio did not change at task failure, the MVC torque produced by the elbow flexors declined by 48% (P < 0.01) with no change in MVC torque for the elbow extensors. While the MEP and CMEP areas (normalized to Mmax) of the biceps brachii increased ( approximately 50%) over the first 40% of the time to task failure and then plateaued, both responses in the triceps brachii increased ( approximately 150-180%) gradually throughout the fatigue task. In contrast to the monotonic increase in the MEP and CMEP of the antagonist muscles, the H-reflex of the triceps brachii exhibited a biphasic modulation, increasing during the first part of the contraction before declining subsequently to 65% of its initial value. Collectively, these results suggest that the level of coactivation during a fatiguing contraction is mediated by supraspinal rather than spinal mechanisms and involves differential control of agonist and antagonist muscles.

Sustained contraction at very low forces produces prominent supraspinal fatigue in human elbow flexor muscles

During sustained maximal voluntary contractions (MVCs), most fatigue occurs within the muscle, but some occurs because voluntary activation of the muscle declines (central fatigue), and some of this reflects suboptimal output from the motor cortex (supraspinal fatigue). This study examines whether supraspinal fatigue occurs during a sustained submaximal contraction of 5% MVC. Eight subjects sustained an isometric elbow flexion of 5% MVC for 70 min. Brief MVCs were performed every 3 min, with stimulation of the motor point, motor cortex, and brachial plexus. Perceived effort and pain, elbow flexion torque, and surface EMGs from biceps and brachioradialis were recorded. During the sustained 5% contraction, perceived effort increased from 0.5 to 3.9 (out of 10), and elbow flexor EMG increased steadily by approximately 60-80%. Torque during brief MVCs fell to 72% of control values, while both the resting twitch and EMG declined progressively. Thus the sustained weak contraction caused fatigue, some of which was due to peripheral mechanisms. Voluntary activation measured by motor point and motor cortex stimulation methods fell to 90% and 80%, respectively. Thus some of the fatigue was central. Calculations based on the fall in voluntary activation measured with cortical stimulation indicate that about two-thirds of the fatigue was due to supraspinal mechanisms. Therefore, sustained performance of a very low-force contraction produces a progressive inability to drive the motor cortex optimally during brief MVCs. The effect of central fatigue on performance of the weak contraction is less clear, but it may contribute to the increase in perceived effort.

Corticomotor excitability contributes to neuromuscular fatigue following marathon running in man

It is unknown whether changes in corticomotor excitability follow prolonged exercise in healthy humans. Furthermore, the role of supraspinal fatigue in decrements of force production and voluntary activation following prolonged exercise has not been established. This study investigated peripheral and central fatigue after a marathon (42.2 km) on a treadmill. Isometric ankle dorsiflexion force and electromyographic responses of the tibialis anterior in response to magnetic stimulation of the peroneal nerve (PNMS) and the motor cortex (TMS) were measured before, immediately after, 4 and 24 h post-marathon (MAR) in nine volunteers (mean +/- s.d. completion time, 208 +/- 22 min). Maximal voluntary contraction decreased by 18 +/- 7% immediately after MAR (P = 0.009) and remained significantly decreased after 4 h. The amplitude of the evoked response to TMS, but not to PNMS, was depressed immediately post-MAR by 57 +/- 25% (P = 0.04). Potentiated resting twitch force was reduced in response to both TMS and PNMS post-MAR (71 +/- 8 and 35 +/- 2% decrease, P = 0.035 and 0.037, respectively), and voluntary activation was reduced to 61.9 +/- 18% immediately post-MAR (P < 0.05). All measures had returned to baseline values after 24 h. These results suggest that fatigue was attributable to both a disturbance of the contractile apparatus within the muscle and submaximal output from the motor cortex.

Use of motor cortex stimulation to measure simultaneously the changes in dynamic muscle properties and voluntary activation in human muscles

Force responses to transcranial magnetic stimulation of motor cortex (TMS) during exercise provide information about voluntary activation and contractile properties of the muscle. Here, TMS-generated twitches and muscle relaxation during the TMS-evoked silent period were measured in fresh, heated, and fatigued muscle. Subjects performed isometric contractions of elbow flexors in two studies. Torque and EMG were recorded from elbow flexor and extensor muscles. One study (n = 6) measured muscle contraction times and relaxation rates during brief maximal and submaximal contractions in fresh and fatigued muscle. Another study (n = 7) aimed to 1) assess the reproducibility of muscle contractile properties during brief voluntary contractions in fresh muscle, 2) validate the technique for contractile properties in passively heated muscle, and 3) apply the technique to study contractile properties during sustained maximal voluntary contractions. In both studies, muscle contractile properties during voluntary contractions were compared with the resting twitch evoked by motor nerve stimulation. Measurement of muscle contractile properties during voluntary contractions is reproducible in fresh muscle and reveals faster and slower muscle relaxation rates in heated and fatigued muscle, respectively. The technique is more sensitive to altered muscle state than the traditional motor nerve resting twitch. Use of TMS during sustained maximal contractions reveals slowing of muscle contraction and relaxation with different time courses and a decline in voluntary activation. Voluntary output from the motor cortex becomes insufficient to maintain complete activation of muscle, although slowing of muscle contraction and relaxation indicates that lower motor unit firing rates are required for fusion of force.

Central excitability does not limit postfatigue voluntary activation of quadriceps femoris

After fatigue, motor evoked potentials (MEP) elicited by transcranial magnetic stimulation and cervicomedullary evoked potentials elicited by stimulation of the corticospinal tract are depressed. These reductions in corticomotor excitability and corticospinal transmission are accompanied by voluntary activation failure, but this may not reflect a causal relationship. Our purpose was to determine whether a decline in central excitability contributes to central fatigue. We hypothesized that, if central excitability limits voluntary activation, then a caffeine-induced increase in central excitability should offset voluntary activation failure. In this repeated-measures study, eight men each attended two sessions. Baseline measures of knee extension torque, maximal voluntary activation, peripheral transmission, contractile properties, and central excitability were made before administration of caffeine (6 mg/kg) or placebo. The amplitude of vastus lateralis MEPs elicited during minimal muscle activation provided a measure of central excitability. After a 1-h rest, baseline measures were repeated before, during, and after a fatigue protocol that ended when maximal voluntary torque declined by 35% (Tlim). Increased prefatigue MEP amplitude ( P = 0.055) and cortically evoked twitch ( P < 0.05) in the caffeine trial indicate that the drug increased central excitability. In the caffeine trial, increased MEP amplitude was correlated with time to task failure ( r = 0.74, P < 0.05). Caffeine potentiated the MEP early in the fatigue protocol ( P < 0.05) and offset the 40% decline in placebo MEP ( P < 0.05) at Tlim. However, this was not associated with enhanced maximal voluntary activation during fatigue or recovery, demonstrating that voluntary activation is not limited by central excitability.

EVIDENCE FOR A SUPRASPINAL CONTRIBUTION TO HUMAN MUSCLE FATIGUE

1. Muscle fatigue can be defined as any exercise-induced loss of ability to produce force with a muscle or muscle group. It involves processes at all levels of the motor pathway between the brain and the muscle. Central fatigue represents the failure of the nervous system to drive the muscle maximally. It is defined as a progressive exercise-induced reduction in voluntary activation or neural drive to the muscle. Supraspinal fatigue is a component of central fatigue. It can be defined as an exercise-induced decline in force caused by suboptimal output from the motor cortex. 2. When stimulus intensity is set appropriately, transcranial magnetic stimulation (TMS) over the motor cortex during an isometric maximal voluntary contraction (MVC) of the elbow flexors commonly evokes a small twitch-like increment in flexion force. This increment indicates that, despite the subject's maximal effort, motor cortical output at the moment of stimulation was not maximal and was not sufficient to drive the motoneurons to produce maximal force from the muscle. An exercise-induced increase in this increment demonstrates supraspinal fatigue. 3. Supraspinal fatigue has been demonstrated during fatiguing sustained and intermittent maximal and submaximal contractions of the elbow flexors where it accounts for about one-quarter of the loss of force of fatigue. It is linked to activity and the development of fatigue in the tested muscles and is little influenced by exercise performed by other muscles. 4. The mechanisms of supraspinal fatigue are unclear. Although changes in the behaviour of cortical neurons and spinal motoneurons occur during fatigue, they can be dissociated from supraspinal fatigue. One factor that may contribute to supraspinal fatigue is the firing of fatigue-sensitive muscle afferents that may act to impair voluntary descending drive.

The effect of sustained low-intensity contractions on supraspinal fatigue in human elbow flexor muscles

Subjects quickly fatigue when they perform maximal voluntary contractions (MVCs). Much of the loss of force is from processes within muscle (peripheral fatigue) but some occurs because voluntary activation of the muscle declines (central fatigue). The role of central fatigue during submaximal contractions is not clear. This study investigated whether central fatigue developed during prolonged low-force voluntary contractions. Subjects (n=9) held isometric elbow flexions of 15% MVC for 43 min. Voluntary activation was measured during brief MVCs every 3 min. During each MVC, transcranial magnetic stimulation (TMS) was followed by stimulation of either brachial plexus or the motor nerve of biceps brachii. After nerve stimulation, a resting twitch was also evoked before subjects resumed the 15% MVC. Perceived effort, elbow flexion torque and surface EMG from biceps, brachioradialis and triceps were recorded. TMS was also given during the sustained 15% MVC. During the sustained contraction, perceived effort rose from approximately 2 to approximately 8 (out of 10) while ongoing biceps EMG increased from 6.9+/-2.1% to 20.0+/-7.8% of initial maximum. Torque in the brief MVCs and the resting twitch fell to 58.6+/-14.5 and 58.2+/-13.2% of control values, respectively. EMG in the MVCs also fell to 62.2+/-15.3% of initial maximum, and twitches evoked by nerve stimulation and TMS grew progressively. Voluntary activation calculated from these twitches fell from approximately 98% to 71.9+/-38.9 and 76.9+/-18.3%, respectively. The silent period following TMS lengthened both in the brief MVCs (by approximately 40 ms) and in the sustained target contraction (by approximately 18 ms). After the end of the sustained contraction, the silent period recovered immediately, voluntary activation and voluntary EMG recovered over several minutes while MVC torque only returned to approximately 85% baseline. The resting twitch showed no recovery. Thus, as well as fatigue in the muscle, the prolonged low-force contraction produced progressive central fatigue, and some of this impairment of the subjects' ability to drive the muscle maximally was due to suboptimal output from the motor cortex. Although caused by a low-force contraction, both the peripheral and central fatigue impaired the production of maximal voluntary force. While central fatigue can only be demonstrated during MVCs, it may have contributed to the disproportionate increase in perceived effort reported during the prolonged low-force contraction.

Short-interval cortical inhibition and corticomotor excitability with fatiguing hand exercise: a central adaptation to fatigue?

The central processes occurring during fatiguing exercise are not well understood, however transcranial magnetic stimulation (TMS) studies have reported increases both in corticomotor excitability, as measured by the motor-evoked potential (MEP) amplitude, and in long-interval intracortical inhibition, as measured by the duration of the post-MEP silent period. To determine whether short-interval cortical inhibition (SICI) is modulated by fatiguing exercise, we used single and paired-pulse TMS to measure MEP amplitude and SICI for the first dorsal interosseous (FDI) and abductor digiti minimi (ADM) muscles of the hand during, and for 20 min after, a 10-min intermittent maximal voluntary abduction of the index finger designed to fatigue the FDI muscle. For the FDI, the index of SICI increased at the onset of exercise (from 0.25+/-0.05 to 0.55+/-0.11, P < 0.05) and then decreased progressively as force declined. At the beginning of recovery, SICI again increased (0.57+/-0.11, P < 0.05) and remained elevated for the 20-min recovery period. In contrast, SICI for ADM did not change during or after exercise. MEP amplitude for both the FDI and ADM increased above baseline during exercise and then decreased below baseline during the recovery period. These results demonstrate that there are significant changes in SICI during and after a fatiguing exercise protocol that are isolated to the representation of the fatigued muscle. The inter-relationship between the changes in excitation and inhibition suggests the presence of a measured and adaptive process of modulation in central excitation and inhibition acting to increase corticomotor drive to the exercising muscle as fatigue is developing.

Effects of Muscle Damage Induced by Eccentric Exercise on Muscle Fatigue

PURPOSE

The present study was designed to determine to what extent muscle damage induced by repetitive eccentric exercise with maximal voluntary effort (ECC) affects the time course of central and peripheral fatigue during sustained maximal voluntary contraction (MVC).

METHODS

Ten healthy male volunteers were asked to perform brief (control MVC) and sustained MVC (fatigue test of 60 s in duration) with elbow flexion before and 2 and 4 d after ECC. Transcranial magnetic stimulation (TMS) was applied to the motor cortex to determine changes in voluntary activation (VA), the size of the motor evoked potential (MEP), and length of electromyographic (EMG) silencing. The ratio of the root mean square value for the surface EMG of the biceps brachii and exerted force within 50 ms before TMS was also calculated (RMS/F).

RESULTS

In two subjects, no significant changes in MVC and muscle soreness were seen after ECC so that their data was excluded from further analysis. Control MVC and muscle soreness was significantly decreased and increased, respectively, 2 and 4 d after ECC compared with that before ECC (P < 0.001). During the fatigue test, VA, which was determined by a phasic increase in the twitch force after TMS, significantly decreased 2 and 4 d after ECC compared with that beforehand (P < 0.01). In addition, the RMS/F was significantly increased 2 and 4 d after ECC (P < 0.001). Although the degree of facilitation of the MEP was significantly increased (P < 0.05), the length of EMG silencing was less affected by ECC.

CONCLUSIONS

Muscle damage and/or muscle soreness induced by repetitive eccentric exercise with maximal effort may be a strong modifier of central and peripheral fatigue during sustained MVC.

Specificity and functional impact of post-exercise depression of cortically evoked motor potentials in man

Magnetic stimulation of the motor cortex with electromyographic recordings from exercising muscles has shown corticospinal excitability to be depressed following exercise. We now investigate whether this depression spreads to non-exercising muscles and its influence on performance. Healthy volunteers made unilateral biceps curls to exhaustion and, in another later session, for 25% of the time to exhaustion. Bilateral motor-evoked potentials (MEPs) in biceps brachii and first dorsal interosseus muscles were measured at 2-min intervals before and after exercise. In another experiment, subjects performed exhaustive curls and, in addition to MEP areas, force production in biceps, hand-grip force, simple reaction times and movement times were measured bilaterally. MEPs were depressed after exhaustive exercise in the exercising biceps for over 60 min; depression was also observed 10-15 min after exercise in the non-exercising biceps but not in the first dorsal interosseus of either hand. The shorter exercise period produced depression of MEPs only in the exercising muscle. After exhaustive exercise maximum voluntary contraction fell in the exercising biceps and this correlated with MEP areas. No reduction in force was seen in the non-exercising biceps but hand-grip force fell slightly in both arms. There was no change in reaction times or movement times. Depression of MEPs can occur in non-exercising homonymous muscles but not in heteronymous muscles and only when exercise levels are high. There was no measurable functional deficit in the non-exercising limb, so we conclude that the reduced corticospinal excitability observed in this limb has little or no consequence on the performance parameters measured.

Effects of exhaustive incremental treadmill exercise on diaphragm and quadriceps motor potentials evoked by transcranial magnetic stimulation

It is unknown whether changes in corticomotor excitability follow exercise in healthy humans. We hypothesized that a fall in the diaphragm and quadriceps motor-evoked potential (MEP) amplitude elicited by transcranial magnetic stimulation of the motor cortex would occur after an incremental exercise task. In 11 healthy subjects, we measured transdiaphragmatic pressure and isometric quadriceps tension in response to supramaximal peripheral magnetic nerve stimulation. MEPs were recorded from these muscles in response to transcranial magnetic stimulation. After baseline measurements, subjects performed a period of submaximal exercise (gentle walking). Measurements were repeated 5 and 20 min after this. The subjects then exercised on a treadmill with an incremental protocol to exhaustion. Transcranial magnetic stimulation was performed at baseline and at 5, 20, 40, and 60 min after exhaustive exercise, and force measurements were obtained at baseline, 20 min, and 60 min. Mean exercise duration was 18 +/- 4 min, and mean maximum heart rate was 172 +/- 10 beats/min. Twitch transdiaphragmatic pressure and twitch isometric quadriceps tension were not different from baseline after exercise, but a significant decrease was observed in diaphragm MEP amplitude 5 and 20 min after exercise (60 +/- 38 and 45 +/- 24%, respectively, of baseline, P = 0.0001). At the same times, the mean quadriceps MEPs were 59 +/- 39 and 74 +/- 32% of baseline (P < 0.0001 and P < 0.01, respectively). Studies using paired stimuli confirmed a likely intracortical mechanism for this depression. Our data confirm significant depression of both diaphragm and quadriceps MEPs after incremental treadmill exercise.

Failure of activation of spinal motoneurones after muscle fatigue in healthy subjects studied by transcranial magnetic stimulation

During a sustained maximal effort a progressive decline in the ability to drive motoneurones (MNs) develops. We used the recently developed triple stimulation technique (TST) to study corticospinal conduction after fatiguing exercise in healthy subjects. This method employs a collision technique to estimate the proportion of motor units activated by a transcranial magnetic stimulus. Following a sustained contraction of the abductor digiti minimi muscle at 50 % maximal force maintained to exhaustion there was an immediate reduction of the TST response from > 95 % to about 60 %. This effect recovered to control levels within 1 min and implies that a decreased number of spinal MNs were excited. Additional TST experiments after maximal and submaximal efforts showed that the decrease in size of the TST response was related to duration and strength of exercise. Motor evoked potentials (MEPs) after conventional transcranial magnetic stimulation (TMS) and responses to peripheral nerve stimulation were recorded following the same fatigue protocol. The size of both the MEPs and the peripheral responses increased after the contraction and were in direct contrast to the decrease in size of the TST response. This points to increased probability of repetitive spinal MN activation during fatigue even if some MNs in the pool failed to discharge. Silent period duration following cortical stimulation lengthened by an average of 55 ms after the contraction and recovered within a time course similar to that of the TST response depression. Overall, the results suggest that the outflow from the motor cortex could become insufficient to drive all spinal MNs to discharge when the muscle is fatigued and that complex interactions between failure of activation and compensatory mechanisms to maintain motor unit activation occur during sustained voluntary activity. When inability to maintain force occurs during submaximal effort, failure of activation of motor units is predominant.

Effect of voluntary facilitation on the diaphragmatic response to transcranial magnetic stimulation

We assessed recruitment curves of the surface diaphragm motor-evoked potential (MEP) after transcranial magnetic stimulation during relaxation and at three different levels of facilitation (20, 40, and 60% of maximal inspiratory esophageal pressure) in 10 healthy subjects (six young and four elderly). MEP amplitude recruitment curves varied between individuals during relaxation and at each level of facilitation. Amplitude recruitment curves during relaxation were reproducible in individual subjects. Inspiratory maneuvers caused a decrease in motor threshold and latency and an increase in MEP amplitude, positively correlated to the intensity of facilitation. These changes were similar in young and elderly subjects. The best fit for MEP amplitude recruitment curves for each condition was obtained with a Boltzmann model. The performance of repeated submaximal inspiratory maneuvers did not affect the amplitude recruitment curves of the relaxed diaphragm. We conclude that the recruitment curve of the diaphragm with transcranial magnetic stimulation is repeatable and changes consistently with facilitation and will, therefore, be a robust experimental tool for the investigation of supraspinal pathways to the diaphragm.