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Montgomery JC. Roles for cerebellum and subsumption architecture in central pattern generation. J Comp Physiol A Neuroethol Sens Neural Behav Physiol 2024; 210:315-324. [PMID: 37130955 PMCID: PMC10994996 DOI: 10.1007/s00359-023-01634-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/04/2023]
Abstract
Within vertebrates, central pattern generators drive rhythmical behaviours, such as locomotion and ventilation. Their pattern generation is also influenced by sensory input and various forms of neuromodulation. These capabilities arose early in vertebrate evolution, preceding the evolution of the cerebellum in jawed vertebrates. This later evolution of the cerebellum is suggestive of subsumption architecture that adds functionality to a pre-existing network. From a central-pattern-generator perspective, what additional functionality might the cerebellum provide? The suggestion is that the adaptive filter capabilities of the cerebellum may be able to use error learning to appropriately repurpose pattern output. Examples may include head and eye stabilization during locomotion, song learning, and context-dependent alternation between learnt motor-control sequences.
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Affiliation(s)
- John C Montgomery
- Institute of Marine Science, University of Auckland, Auckland, New Zealand.
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2
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Viana Di Prisco G, Marlinski V, Beloozerova IN. Activity of cat premotor cortex neurons during visually guided stepping. J Neurophysiol 2023; 130:838-860. [PMID: 37609687 PMCID: PMC10642938 DOI: 10.1152/jn.00114.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/13/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023] Open
Abstract
Visual control of steps is critical in everyday life. Several motor centers are implicated in visual control of steps on a complex surface, however, participation of a large cortical motor area, the premotor cortex, in visual guidance of steps during overground locomotion has not been examined. Here, we analyzed the activity of neurons in feline premotor cortex areas 6aα and 6aγ as cats walked on the flat surface where visual guidance of steps is not needed and stepped on crosspieces of a horizontally placed ladder or over barriers where visual control of steps is required. The comparison of neuronal firing between vision-dependent and vision-independent stepping revealed components of the activity related to visual guidance of steps. We found that the firing activity of 59% of neurons was modulated with the rhythm of strides on the flat surface, and the activity of 83-86% of the population changed upon transition to locomotion on the ladder or with barriers. The firing rate and the depth of the stride-related activity modulation of 33-44% of neurons changed, and the stride phases where neurons preferred to fire changed for 58-73% of neurons. These results indicate that a substantial proportion of areas 6aα and 6aγ neurons is involved in visual guidance of steps. Compared with the primary motor cortex, the proportion of cells, the firing activity of which changed upon transition from vision-independent to vision-dependent stepping, was lower and the preferred phases of the firing activity changed more often between the tasks.NEW & NOTEWORTHY Visual control of steps is critical for daily living, however, how it is achieved is not well understood. Here, we analyzed how neurons in the premotor cortex respond to the demand for visual control of steps on a complex surface. We conclude that premotor cortex neurons participate in the cortical network supporting visual control of steps by modifying the phase, intensity, and salience of their firing activity.
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Affiliation(s)
- Gonzalo Viana Di Prisco
- Stark Neurosciences Research Institute, Indiana University, Indianapolis, Indiana, United States
- Barrow Neurological Institute, St. Joseph's Hospital & Medical Center, Phoenix, Arizona, United States
| | - Vladimir Marlinski
- Barrow Neurological Institute, St. Joseph's Hospital & Medical Center, Phoenix, Arizona, United States
| | - Irina N Beloozerova
- Barrow Neurological Institute, St. Joseph's Hospital & Medical Center, Phoenix, Arizona, United States
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia, United States
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3
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Lambert FM, Beraneck M, Straka H, Simmers J. Locomotor efference copy signaling and gaze control: An evolutionary perspective. Curr Opin Neurobiol 2023; 82:102761. [PMID: 37604066 DOI: 10.1016/j.conb.2023.102761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/08/2023] [Accepted: 07/22/2023] [Indexed: 08/23/2023]
Abstract
Neural replicas of the spinal motor commands that drive locomotion have become increasingly recognized as an intrinsic neural mechanism for producing gaze-stabilizing eye movements that counteract the perturbing effects of self-generated head/body motion. By pre-empting reactive signaling by motion-detecting vestibular sensors, such locomotor efference copies (ECs) provide estimates of the sensory consequences of behavioral action. Initially demonstrated in amphibian larvae during spontaneous fictive swimming in deafferented in vitro preparations, direct evidence for a contribution of locomotor ECs to gaze stabilization now extends to the ancestral lamprey and to tetrapod adult frogs and mice. Supporting behavioral evidence also exists for other mammals, including humans, therefore further indicating the mechanism's conservation during vertebrate evolution. The relationship between feedforward ECs and vestibular sensory feedback in ocular movement control is variable, ranging from additive to the former supplanting the latter, depending on vestibular sensing ability, and the intensity and regularity of rhythmic locomotor movements.
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Affiliation(s)
- François M Lambert
- Institut des Neurosciences Cognitives et Intégratives d'Aquitaine, CNRS Unité Mixte de Recherche 5287, Université de Bordeaux, 33706 Bordeaux, France
| | - Mathieu Beraneck
- Integrative Neuroscience and Cognition Center, CNRS UMR 8002, Université Paris Cité, 75006 Paris, France
| | - Hans Straka
- Department Biology II, Ludwig-Maximilians-University Munich, 82152 Planegg, Germany
| | - John Simmers
- Institut des Neurosciences Cognitives et Intégratives d'Aquitaine, CNRS Unité Mixte de Recherche 5287, Université de Bordeaux, 33706 Bordeaux, France.
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Beloozerova IN, Nilaweera WU, Viana Di Prisco G, Marlinski V. Signals from posterior parietal area 5 to motor cortex during locomotion. Cereb Cortex 2022; 33:1014-1043. [PMID: 35383368 PMCID: PMC9930630 DOI: 10.1093/cercor/bhac118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/14/2022] Open
Abstract
Area 5 of the parietal cortex is part of the "dorsal stream" cortical pathway which processes visual information for action. The signals that area 5 ultimately conveys to motor cortex, the main area providing output to the spinal cord, are unknown. We analyzed area 5 neuronal activity during vision-independent locomotion on a flat surface and vision-dependent locomotion on a horizontal ladder in cats focusing on corticocortical neurons (CCs) projecting to motor cortex from the upper and deeper cortical layers and compared it to that of neighboring unidentified neurons (noIDs). We found that upon transition from vision-independent to vision-dependent locomotion, the low discharge of CCs in layer V doubled and the proportion of cells with 2 bursts per stride tended to increase. In layer V, the group of 2-bursters developed 2 activity peaks that coincided with peaks of gaze shifts along the surface away from the animal, described previously. One-bursters and either subpopulation in supragranular layers did not transmit any clear unified stride-related signal to the motor cortex. Most CC group activities did not mirror those of their noID counterparts. CCs with receptive fields on the shoulder, elbow, or wrist/paw discharged in opposite phases with the respective groups of pyramidal tract neurons of motor cortex, the cortico-spinal cells.
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Affiliation(s)
- Irina N Beloozerova
- Corresponding author: School of Biological Sciences, Georgia Institute of Technology, 555 14th Street, Atlanta, GA, 30332, USA.
| | - Wijitha U Nilaweera
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ, 85013, USA,Des Moines Area Community College, 2006 South Ankeny Blvd., Ankeny, IA, 50023, USA
| | - Gonzalo Viana Di Prisco
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ, 85013, USA,Stark Neurosciences Research Institute, Indiana University, 320 West 15th Street, Indianapolis, IN, 46202, USA
| | - Vladimir Marlinski
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ, 85013, USA
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Volgushev M, Nguyen CT, Iyer GS, Beloozerova IN. When cats need to see to step accurately? J Physiol 2022; 600:75-94. [PMID: 34761816 PMCID: PMC9241584 DOI: 10.1113/jp282255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/29/2021] [Indexed: 01/03/2023] Open
Abstract
Locomotion on complex terrains often requires vision. However, how vision serves locomotion is not well understood. Here, we asked when visual information necessary for accurate stepping is collected and how its acquisition relates to the step cycle. In cats of both sexes, we showed that a brief (200-400 ms) interruption of visual input can rapidly influence cat's walking along a horizontal ladder. Depending on the phase within the step cycle, a 200 ms period of darkness could be tolerated fully without any changes to the strides or could lead to minor increases of stride duration. The effects of 300-400 ms of visual input denial, which typically prolonged stances and/or swings, also depended on the phase of the darkness onset. The increase of the duration of strides was always shorter than the duration of darkness. We conclude that visual information for planning a swing is collected starting from the middle of the preceding stance until the beginning of the current swing. For a stance (and/or a swing of the other paw), visual information is collected starting from the end of the previous stance and until the middle of the current stance. Acquisition of visual information during these windows is not uniform but depends on the phase of the step cycle. Notably, both the extension of these windows and their non-homogeneity are closely related to the pattern of gaze behaviour in cats, described previously. This new knowledge will help to guide research and understanding of neuronal mechanisms of visuomotor integration and modulation of visual function by strides during locomotion. KEY POINTS: Cats, like humans, rely on vision to navigate in complex environments. In cats walking along a horizontally placed ladder, we show that visual information required for accurate stepping is collected in a non-uniform manner throughout the stride cycle. Brief denial of visual input during a swing prolongs the next stance of that forelimb. Denial of visual input during a stance prolongs this stance, as well as the next swing and stance. Denial during the first half of a stance has a greater effect than during the second half. The phase dependence of the use of vision for accurate stepping and the pattern of affected swings and stances are closely related to the previously described pattern of gaze behaviour in cats. This new knowledge opens new perspectives for research into neuronal mechanisms of visuomotor coordination and visual function during walking and for understanding related disorders.
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Affiliation(s)
- Maxim Volgushev
- Department of Psychological Sciences, University of
Connecticut, Storrs, CT, USA
| | - Celina T. Nguyen
- Barrow Neurological Institute, St Joseph’s Hospital
and Medical Center, Phoenix, AZ, USA
- Neurosciences Graduate Program, University of California
San Diego, La Jolla, CA, USA
| | - Gautam S. Iyer
- Barrow Neurological Institute, St Joseph’s Hospital
and Medical Center, Phoenix, AZ, USA
| | - Irina N. Beloozerova
- Barrow Neurological Institute, St Joseph’s Hospital
and Medical Center, Phoenix, AZ, USA
- School of Biological Sciences, Georgia Institute of
Technology, Atlanta, GA, USA
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6
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Beloozerova IN. Neuronal activity reorganization in motor cortex for successful locomotion after a lesion in the ventrolateral thalamus. J Neurophysiol 2022; 127:56-85. [PMID: 34731070 PMCID: PMC8742732 DOI: 10.1152/jn.00191.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Thalamic stroke leads to ataxia if the cerebellum-receiving ventrolateral thalamus (VL) is affected. The compensation mechanisms for this deficit are not well understood, particularly the roles that single neurons and specific neuronal subpopulations outside the thalamus play in recovery. The goal of this study was to clarify neuronal mechanisms of the motor cortex involved in mitigation of ataxia during locomotion when part of the VL is inactivated or lesioned. In freely ambulating cats, we recorded the activity of neurons in layer V of the motor cortex as the cats walked on a flat surface and horizontally placed ladder. We first reversibly inactivated ∼10% of the VL unilaterally using glutamatergic transmission antagonist CNQX and analyzed how the activity of motor cortex reorganized to support successful locomotion. We next lesioned 50%-75% of the VL bilaterally using kainic acid and analyzed how the activity of motor cortex reorganized when locomotion recovered. When a small part of the VL was inactivated, the discharge rates of motor cortex neurons decreased, but otherwise the activity was near normal, and the cats walked fairly well. Individual neurons retained their ability to respond to the demand for accuracy during ladder locomotion; however, most changed their response. When the VL was lesioned, the cat walked normally on the flat surface but was ataxic on the ladder for several days after lesion. When ladder locomotion normalized, neuronal discharge rates on the ladder were normal, and the shoulder-related group was preferentially active during the stride's swing phase.NEW & NOTEWORTHY This is the first analysis of reorganization of the activity of single neurons and subpopulations of neurons related to the shoulder, elbow, or wrist, as well as fast- and slow-conducting pyramidal tract neurons in the motor cortex of animals walking before and after inactivation or lesion in the thalamus. The results offer unique insights into the mechanisms of spontaneous recovery after thalamic stroke, potentially providing guidance for new strategies to alleviate locomotor deficits after stroke.
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Affiliation(s)
- Irina N. Beloozerova
- 1School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia,2Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
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Arlegi M, Pantoja-Pérez A, Veschambre-Couture C, Gómez-Olivencia A. Covariation between the cranium and the cervical vertebrae in hominids. J Hum Evol 2021; 162:103112. [PMID: 34894608 DOI: 10.1016/j.jhevol.2021.103112] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022]
Abstract
The analysis of patterns of integration is crucial for the reconstruction and understanding of how morphological changes occur in a taxonomic group throughout evolution. These patterns are relatively constant; however, both patterns and the magnitudes of integration may vary across species. These differences may indicate morphological diversification, in some cases related to functional adaptations to the biomechanics of organisms. In this study, we analyze patterns of integration between two functional and developmental structures, the cranium and the cervical spine in hominids, and we quantify the amount of divergence of each anatomical element through phylogeny. We applied these methods to three-dimensional data from 168 adult hominid individuals, summing a total of more than 1000 cervical vertebrae. We found the atlas (C1) and axis (C2) display the lowest covariation with the cranium in hominids (Homo sapiens, Pan troglodytes, Pan paniscus, Gorilla gorilla, Gorilla beringei, Pongo pygmaeus). H. sapiens show a relatively different pattern of craniocervical correlation compared with chimpanzees and gorillas, especially in variables implicated in maintaining the balance of the head. Finally, the atlas and axis show lower magnitude of shape change during evolution than the rest of the cervical vertebrae, especially those located in the middle of the subaxial cervical spine. Overall, results suggest that differences in the pattern of craniocervical correlation between humans and gorillas and chimpanzees could reflect the postural differences between these groups. Also, the stronger craniocervical integration and larger magnitude of shape change during evolution shown by the middle cervical vertebrae suggests that they have been selected to play an active role in maintaining head balance.
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Affiliation(s)
- Mikel Arlegi
- Institut Català de Paleoecologia Humana i Evolució Social (IPHES-CERCA), Zona Educacional 4, Campus Sescelades URV (Edifici W3), 43007 Tarragona, Spain; Universitat Rovira i Virgili, Department d'Història i Història de l'Art, Avinguda de Catalunya 35, 43002 Tarragona, Spain.
| | - Ana Pantoja-Pérez
- Centro UCM-ISCIII de Investigación sobre Evolución y Comportamiento Humanos, Avda. Monforte de Lemos 5 (Pabellón 14), 28029 Madrid, Spain
| | - Christine Veschambre-Couture
- UMR 5199 PACEA, Université de Bordeaux, Allée Geoffroy Saint Hilaire, Bâtiment B8, CS 50023, 33615, Pessac Cedex, France
| | - Asier Gómez-Olivencia
- Departamento de Geología, Facultad de Ciencia y Tecnología, Universidad del País Vasco-Euskal Herriko Unibertsitatea (UPV/EHU), Barrio Sarriena S/n, 48940 Leioa, Spain; Sociedad de Ciencias Aranzadi, Zorroagagaina 11, 20014 Donostia-San Sebastián, Spain; Centro UCM-ISCIII de Investigación sobre Evolución y Comportamiento Humanos, Avda. Monforte de Lemos 5 (Pabellón 14), 28029 Madrid, Spain
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França de Barros F, Bacqué-Cazenave J, Taillebuis C, Courtand G, Manuel M, Bras H, Tagliabue M, Combes D, Lambert FM, Beraneck M. Conservation of locomotion-induced oculomotor activity through evolution in mammals. Curr Biol 2021; 32:453-461.e4. [PMID: 34856124 DOI: 10.1016/j.cub.2021.11.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/04/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
Efference copies are neural replicas of motor outputs used to anticipate the sensory consequences of a self-generated motor action or to coordinate neural networks involved in distinct motor behaviors.1 An established example of this motor-to-motor coupling is the efference copy of the propulsive motor command, which supplements classical visuo-vestibular reflexes to ensure gaze stabilization during amphibian larval locomotion.2 Such feedforward replica of spinal pattern-generating circuits produces a spino-extraocular motor coupled activity that evokes eye movements, spatiotemporally coordinated to tail undulation independently of any sensory signal.3,4 Exploiting the developmental stages of the frog,1 studies in metamorphing Xenopus demonstrated the persistence of this spino-extraocular motor command in adults and its developmental adaptation to tetrapodal locomotion.5,6 Here, we demonstrate for the first time the existence of a comparable locomotor-to-ocular motor coupling in the mouse. In neonates, ex vivo nerve recordings of brainstem-spinal cord preparations reveal a spino-extraocular motor coupled activity similar to the one described in Xenopus. In adult mice, trans-synaptic rabies virus injections in lateral rectus eye muscle label cervical spinal cord neurons closely connected to abducens motor neurons. Finally, treadmill-elicited locomotion in decerebrated preparations7 evokes rhythmic eye movements in synchrony with the limb gait pattern. Overall, our data are evidence for the conservation of locomotor-induced eye movements in vertebrate lineages. Thus, in mammals as in amphibians, CPG-efference copy feedforward signals might interact with sensory feedback to ensure efficient gaze control during locomotion.
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Affiliation(s)
- Filipa França de Barros
- Université de Paris, CNRS, Integrative Neuroscience and Cognition Center, F-75006 Paris, France
| | - Julien Bacqué-Cazenave
- Institut des Neurosciences Cognitives et Intégratives d'Aquitaine, INCIA CNRS UMR 5287, 33076 Université de Bordeaux, Bordeaux, France
| | - Coralie Taillebuis
- Université de Paris, CNRS, Integrative Neuroscience and Cognition Center, F-75006 Paris, France; Institut des Neurosciences Cognitives et Intégratives d'Aquitaine, INCIA CNRS UMR 5287, 33076 Université de Bordeaux, Bordeaux, France
| | - Gilles Courtand
- Institut des Neurosciences Cognitives et Intégratives d'Aquitaine, INCIA CNRS UMR 5287, 33076 Université de Bordeaux, Bordeaux, France
| | - Marin Manuel
- Université de Paris, CNRS, Saints-Pères Institute for the Neurosciences, F-75006 Paris, France; Department of Biomedical and Pharmaceutical Sciences and George and Anne Ryan Institute for Neuroscience, University of Rhode Island, Kingston, RI, USA
| | - Hélène Bras
- Institut de Neurosciences de la Timone, UMR 7289 CNRS-AMU, 13385 Marseille, France
| | - Michele Tagliabue
- Université de Paris, CNRS, Integrative Neuroscience and Cognition Center, F-75006 Paris, France
| | - Denis Combes
- Institut des Neurosciences Cognitives et Intégratives d'Aquitaine, INCIA CNRS UMR 5287, 33076 Université de Bordeaux, Bordeaux, France
| | - François M Lambert
- Institut des Neurosciences Cognitives et Intégratives d'Aquitaine, INCIA CNRS UMR 5287, 33076 Université de Bordeaux, Bordeaux, France.
| | - Mathieu Beraneck
- Université de Paris, CNRS, Integrative Neuroscience and Cognition Center, F-75006 Paris, France.
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Beloozerova IN, Marlinski V. Contribution of the ventrolateral thalamus to the locomotion-related activity of motor cortex. J Neurophysiol 2020; 124:1480-1504. [PMID: 32783584 DOI: 10.1152/jn.00253.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The activity of motor cortex is necessary for accurate stepping on a complex terrain. How this activity is generated remains unclear. The goal of this study was to clarify the contribution of signals from the ventrolateral thalamus (VL) to formation of locomotion-related activity of motor cortex during vision-independent and vision-dependent locomotion. In two cats, we recorded the activity of neurons in layer V of motor cortex as cats walked on a flat surface and a horizontal ladder. We reversibly inactivated ~10% of the VL unilaterally with the glutamatergic transmission antagonist 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) and analyzed how this affected the activity of motor cortex neurons. We examined neuronal subpopulations with somatosensory receptive fields on different segments of the forelimb and pyramidal tract projecting neurons (PTNs). We found that the VL contribution to the locomotion-related activity of motor cortex is very powerful and has both excitatory and inhibitory components. The magnitudes of both the excitatory and inhibitory contributions fluctuate over the step cycle and depend on locomotion task. On a flat surface, the VL contributes more excitation to the shoulder- and elbow-related neurons than the wrist/paw-related cells. The VL excites the shoulder-related group the most during the transition from stance to swing phase, while most intensively exciting the elbow-related group during the transition from swing to stance. The VL contributes more excitation for the fast- than slow-conducting PTNs. Upon transition to vision-dependent locomotion on the ladder, the VL contribution increases more for the wrist/paw-related neurons and slow-conducting PTNs.NEW & NOTEWORTHY How the activity of motor cortex is generated and the roles that different inputs to motor cortex play in formation of response properties of motor cortex neurons during movements remain unclear. This is the first study to characterize the contribution of the input from the ventrolateral thalamus (VL), the main subcortical input to motor cortex, to the activity of motor cortex neurons during vision-independent and vision-dependent locomotion.
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Affiliation(s)
- Irina N Beloozerova
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia.,Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Vladimir Marlinski
- Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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