Ashlee M. Hendy

Corticospinal adaptations and strength maintenance in the immobilized arm following 3 weeks unilateral strength training

Cross‐education strength training has being shown to retain strength and muscle thickness in the immobilized contralateral limb. Corticospinal mechanisms have been proposed to underpin this phenomenon; however, no transcranial magnetic stimulation (TMS) data has yet been presented. This study used TMS to measure corticospinal responses following 3 weeks of unilateral arm training on the contralateral, immobilize arm. Participants (n = 28) were randomly divided into either immobilized strength training (Immob + train) immobilized no training (Immob) or control. Participants in the immobilized groups had their nondominant arm rested in a sling, 15 h/day for 3 weeks. The Immob + train group completed unilateral arm curl strength training, while the Immob and control groups did not undertake training. All participants were tested for corticospinal excitability, strength, and muscle thickness of both arms. Immobilization resulted in a group x time significant reduction in strength, muscle thickness and corticospinal excitability for the untrained limb of the Immob group. Conversely, no significant change in strength, muscle thickness, or corticospinal excitability occurred in the untrained limb of the Immob + train group. These results provide the first evidence of corticospinal mechanisms, assessed by TMS, underpinning the use of unilateral strength training to retain strength and muscle thickness following immobilization of the contralateral limb.

Cross education and immobilisation: Mechanisms and implications for injury rehabilitation

OBJECTIVES Unilateral strength training produces an increase in strength of the contralateral homologous muscle group. This process of strength transfer, known as cross education, is generally attributed to neural adaptations. It has been suggested that unilateral strength training of the free limb may assist in maintaining the functional capacity of an immobilised limb via cross education of strength, potentially enhancing recovery outcomes following injury. Therefore, the purpose of this review is to examine the impact of immobilisation, the mechanisms that may contribute to cross education, and possible implications for the application of unilateral training to maintain strength during immobilisation. DESIGN Critical review of literature. METHODS Search of online databases. RESULTS Immobilisation is well known for its detrimental effects on muscular function. Early reductions in strength outweigh atrophy, suggesting a neural contribution to strength loss, however direct evidence for the role of the central nervous system in this process is limited. Similarly, the precise neural mechanisms responsible for cross education strength transfer remain somewhat unknown. Two recent studies demonstrated that unilateral training of the free limb successfully maintained strength in the contralateral immobilised limb, although the role of the nervous system in this process was not quantified. CONCLUSIONS Cross education provides a unique opportunity for enhancing rehabilitation following injury. By gaining an understanding of the neural adaptations occurring during immobilisation and cross education, future research can utilise the application of unilateral training in clinical musculoskeletal injury rehabilitation.

Anodal tdcs Applied during Strength Training Enhances Motor Cortical Plasticity

PURPOSE The objective of this study was to assess the effect of anodal transcranial direct current stimulation (a-tDCS) on voluntary dynamic strength and cortical plasticity when applied during a 3-wk strength training program for the wrist extensors. METHODS Thirty right-handed participants were randomly allocated to the tDCS, sham, or control group. The tDCS and sham group underwent 3 wk of heavy-load strength training of the right wrist extensors, with 20 min of a-tDCS (2 mA) or sham tDCS applied during training (double blinded). Outcome measures included voluntary dynamic wrist extension strength, muscle thickness, corticospinal excitability, short-interval intracortical inhibition (SICI), and silent period duration. RESULTS Maximal voluntary strength increased in both the tDCS and sham groups (14.89% and 11.17%, respectively, both P < 0.001). There was no difference in strength gain between the two groups (P = 0.229) and no change in muscle thickness (P = 0.15). The tDCS group demonstrated an increase in motor-evoked potential amplitude at 15%, 20%, and 25% above active motor threshold, which was accompanied by a decrease in SICI during 50% maximal voluntary isometric contraction and 20% maximal voluntary isometric contraction (all P < 0.05). Silent period decreased for both the tDCS and sham groups (P < 0.001). CONCLUSION The application of a-tDCS in combination with strength training of the wrist extensors in a healthy population did not provide additional benefit for voluntary dynamic strength gains when compared with standard strength training. However, strength training with a-tDCS appears to differentially modulate cortical plasticity via increases in corticospinal excitability and decreases in SICI, which did not occur following strength training alone.

Does a Combination of Virtual Reality, Neuromodulation and Neuroimaging Provide a Comprehensive Platform for Neurorehabilitation? – A Narrative Review of the Literature

In the last decade, virtual reality (VR) training has been used extensively in video games and military training to provide a sense of realism and environmental interaction to its users. More recently, VR training has been explored as a possible adjunct therapy for people with motor and mental health dysfunctions. The concept underlying VR therapy as a treatment for motor and cognitive dysfunction is to improve neuroplasticity of the brain by engaging users in multisensory training. In this review, we discuss the theoretical framework underlying the use of VR as a therapeutic intervention for neurorehabilitation and provide evidence for its use in treating motor and mental disorders such as cerebral palsy, Parkinson’s disease, stroke, schizophrenia, anxiety disorders, and other related clinical areas. While this review provides some insights into the efficacy of VR in clinical rehabilitation and its complimentary use with neuroimaging (e.g., fNIRS and EEG) and neuromodulation (e.g., tDCS and rTMS), more research is needed to understand how different clinical conditions are affected by VR therapies (e.g., stimulus presentation, interactivity, control and types of VR). Future studies should consider large, longitudinal randomized controlled trials to determine the true potential of VR therapies in various clinical populations.

Anodal transcranial direct current stimulation prolongs the cross-education of strength and corticomotor plasticity

PURPOSE This study aimed to assess the efficacy of applying anodal transcranial direct-current stimulation (a-tDCS) to the ipsilateral motor cortex (iM1) during unilateral strength training to enhance the neurophysiological and functional effects of cross-education. METHODS Twenty-four healthy volunteers were randomly allocated to perform either of the following: strength training during a-tDCS (ST + a-tDCS), strength training during sham tDCS (ST + sham), or a-tDCS during rest (a-tDCS) across 2 wk. Strength training of the right biceps brachii involved four sets of six repetitions at 80% of one-repetition maximum three times per week. Anodal tDCS was applied to the iM1 at 1.5 mA for 15 min during each strength training session. Outcome measures included one-repetition maximum strength of the untrained biceps brachii, corticomotoneuronal excitability, cross-activation, and short-interval intracortical inhibition (SICI) of the iM1 determined by transcranial magnetic stimulation. RESULTS Immediately after the final training session, there was an increase in strength for both the ST + a-tDCS (12.5%, P < 0.001) and the ST + sham group (9.4%, P = 0.007), which was accompanied by significant increases in corticomotoneuronal excitability and decreases in SICI for both groups. After a 48-h retention period, strength increase was maintained in the ST + a-tDCS (13.0%, P = 0.001) group, which was significantly greater than the ST + sham group (7.6%, P = 0.039). Similarly, increases in corticomotoneuronal excitability and decreases in SICI were maintained in the ST + a-tDCS group but not in the ST + sham group. No main effects were reported for the a-tDCS group (all P > 0.05). CONCLUSIONS The addition of a-tDCS to the iM1 during unilateral strength training prolongs the benefits of cross-education, which may have significant implications to enhancement of rehabilitation outcomes after a single-limb injury or impairment.

Lower limb progressive resistance training improves leg strength but not gait speed or balance in Parkinson's disease: A systematic review and meta-analysis

The use of progressive resistance training (PRT) to improve gait and balance in people with Parkinson’s disease (PD) is an emerging area of interest. However, the main effects of PRT on lower limb functions such as gait, balance, and leg strength in people with PD remain unclear. Therefore, the aim of the meta-analysis is to evaluate the evidence surrounding the use of PRT to improve gait and balance in people with PD. Five electronic databases, from inception to December 2014, were searched to identify the relevant studies. Data extraction was performed by two independent reviewers and methodological quality was assessed using the PEDro scale. Standardized mean differences (SMD) and 95% confidence intervals (CIs) of fixed and random effects models were used to calculate the effect sizes between experimental and control groups and I2 statistics were used to determine levels of heterogeneity. In total, seven studies were identified consisting of 172 participants (experimental n = 84; control n = 88). The pooled results showed a moderate but significant effect of PRT on leg strength (SMD 1.42, 95% CI 0.464–2.376); however, no significant effects were observed for gait speed (SMD 0.418, 95% CI −0.219 to 1.055). No significant effects were observed for balance measures included in this review. In conclusion, our results showed no discernable effect of PRT on gait and balance measures, although this is likely due to the lack of studies available. It may be suggested that PRT be performed in conjunction with balance or task-specific functional training to elicit greater lower limb functional benefits in people with PD.

Measures to Predict The Individual Variability of Corticospinal Responses Following Transcranial Direct Current Stimulation

Individual responses to transcranial direct current stimulation (tDCS) are varied and therefore potentially limit its application. There is evidence that this variability is related to the contributions of Indirect waves (I-waves) recruited in the cortex. The latency of motor-evoked potentials (MEPs) can be measured through transcranial magnetic stimulation (TMS), allowing an individual’s responsiveness to tDCS to be determined. However, this single-pulse method requires several different orientations of the TMS coil, potentially affecting its reliability. Instead, we propose a paired-pulse TMS paradigm targeting I-waves as an alternative method. This method uses one orientation that reduces inter- and intra-trial variability. It was hypothesized that the paired-pulse method would correlate more highly to tDCS responses than the single-pulse method. In a randomized, double blinded, cross-over design, 30 healthy participants completed two sessions, receiving 20 min of either anodal (2 mA) or sham tDCS. TMS was used to quantify Short interval intracortical facilitation (SICF) at Inter stimulus intervals (ISIs) of 1.5, 3.5 and 4.5 ms. Latency was determined in the posterior-anterior (PA), anterior-posterior (AP) and latero-medial (LM) coil orientations. The relationship between latency, SICF measures and the change in suprathreshold MEP amplitude size following tDCS were determined with Pearson’s correlations. TMS measures, SICI and SICF were also used to determine responses to Anodal-tDCS (a-tDCS). Neither of the latency differences nor the SICF measures correlated to the change in MEP amplitude from pre-post tDCS (all P > 0.05). Overall, there was no significant response to tDCS in this cohort. This study highlights the need for testing the effects of various tDCS protocols on the different I-waves. Further research into SICF and whether it is a viable measure of I-wave facilitation is warranted.

The cross-education phenomenon: brain and beyond

Objectives: Unilateral resistance training produces strength gains in the untrained homologous muscle group, an effect termed “cross-education.” The observed strength transfer has traditionally been considered a phenomenon of the nervous system, with few studies examining the contribution of factors beyond the brain and spinal cord. In this hypothesis and theory article, we aim to discuss further evidence for structural and functional adaptations occurring within the nervous, muscle, and endocrine systems in response to unilateral resistance training. The limitations of existing cross-education studies will be explored, and novel potential stakeholders that may contribute to the cross-education effect will be identified. Design: Critical review of the literature. Method: Search of online databases. Results: Studies have provided evidence that functional reorganization of the motor cortex facilitates, at least in part, the effects of cross-education. Cross-activation of the “untrained” motor cortex, ipsilateral to the trained limb, plays an important role. While many studies report little or no gains in muscle mass in the untrained limb, most experimental designs have not allowed for sensitive or comprehensive investigation of structural changes in the muscle. Conclusions: Increased neural drive originating from the “untrained” motor cortex contributes to the cross-education effect. Adaptive changes within the muscle fiber, as well as systemic and hormonal factors require further investigation. An increased understanding of the physiological mechanisms contributing to cross-education will enable to more effectively explore its effects and potential applications in rehabilitation of unilateral movement disorders or injury.

The Time-Course of Acute Changes in Corticospinal Excitability, Intra-Cortical Inhibition and Facilitation Following a Single-Session Heavy Strength Training of the Biceps Brachii

Objective: The current understanding of acute neurophysiological responses to resistance training remains unclear. Therefore, we aimed to compare the time-course of acute corticospinal responses following a single-session heavy strength training (HST) of the biceps brachii (BB) muscle and provide quantifiable evidence based on the super-compensation model in an applied setting. Methods: Fourteen participants completed a counter-balanced, cross-over study that consisted of a single HST session (5 sets × 3 repetition maximum [RM]) of the BB and a control session (CON). Single- and paired-pulse transcranial magnetic stimulation (TMS) was used to measure changes in motor-evoked potential (MEP) amplitude, intra-cortical facilitation (ICF), short-interval intra-cortical inhibition (SICI) and long-interval intra-cortical inhibition (LICI). Additionally, maximal muscle compound wave (MMAX) and maximal voluntary isometric contraction (MVIC) of the BB were taken. All measures were taken at baseline, immediately post and at 10, 20, 30 min and 1, 2, 6, 24, 48 and 72 h post-training. Results: A significant reduction in MEP amplitude was observed immediately post training (P = 0.001), while MVIC (P < 0.001) and MMAX (P = 0.047) were reduced for up to 30 min post-training. An increase in MVIC (p < 0.001) and MMAX (p = 0.047) was observed at 6 h, while an increase in MEP amplitude (p = 0.014) was only observed at 48 and 72 h. No changes in SICI, ICF and LICI were observed. Conclusion: Our results suggest that: (1) acute changes in corticospinal measures returned to baseline in a shorter timeframe than the current super-compensation model (24–48 h) and (2) changes in corticospinal excitability post-HST may be modulated “downstream” of the primary motor cortex (M1).

Cross-Activation of the Motor Cortex during Unilateral Contractions of the Quadriceps

Transcranial magnetic stimulation (TMS) studies have demonstrated that unilateral muscle contractions in the upper limb produce motor cortical activity in both the contralateral and ipsilateral motor cortices. The increase in excitability of the corticomotor pathway activating the resting limb has been termed “cross-activation”, and is of importance due to its involvement in cross-education and rehabilitation. To date, very few studies have investigated cross-activation in the lower limb. Sixteen healthy participants (mean age 29 ± 9 years) took part in this study. To determine the effect of varying contraction intensities in the lower limb, we investigated corticomotor excitability and intracortical inhibition of the right rectus femoris (RF) while the left leg performed isometric extension at 0%, 25%, 50%, 75% and 100% of maximum force output. Contraction intensities of 50% maximal force output and greater produced significant cross-activation of the corticomotor pathway. A reduction in silent period duration was observed during 75% and 100% contractions, while the release of short-interval intracortical inhibition (SICI) was only observed during maximal (100%) contractions. We conclude that increasing isometric contraction intensities produce a monotonic increase in cross-activation, which was greatest during 100% force output. Unilateral training programs designed to induce cross-education of strength in the lower limb should therefore be prescribed at the maximal intensity tolerable.