Single fiber EMG in juvenile idiopathic scoliosis

A single fiber EMG (SFEMG) study was performed in 51 patients with idiopathic juvenile scoliosis of moderate degree (mean 23.8 degrees of Cobb), aged 7-18 years (mean 13.2 years). The findings in the extensor digitorum communis muscle (EDC) include a moderate but significant increase in fiber density (mean 2.02, +/- 0.21, P less than 0.001), a mild but significant (P less than 0.001) neuromuscular transmission abnormality (7.6% of fibers showed increased jitter and 4.5% intermittent blocking), and a moderately prolonged mean interspike interval (mean 0.98 msec, +/- 0.20, P less than 0.005) in EDC. Five of the patients had normal fiber density, 9 had a normal jitter study, and further 7 had a normal mean interspike interval. However only one had all the parameters normal. The paraspinal and intercostal muscles at the apex of the scoliotic curvature examined in some of the patients showed similar abnormalities. The study thus suggests the existence of a subclinical systemic neuromuscular disorder in nearly all of our patients with idiopathic scoliosis, which might have a pathogenetic significance.     

Prolonged myasthenic syndrome after one week of muscle relaxants

A child developed severe, generalized muscle weakness which persisted for 6 weeks, after receiving muscle relaxants for 1 week while requiring ventilator support. Electrodiagnostic studies indicated a presynaptic disorder of the neuromuscular junction which improved with high-frequency stimulation, similar to findings in Lambert-Eaton syndrome. Muscle specimens exhibited neurogenic targetoid fiber atrophy. Ultrastructure of the neuromuscular junction indicated terminal axon degeneration and atrophy with depletion of the secretory vesicles. Most reported patients with post-ventilator paresis have received steroids and muscle relaxants; muscle weakness commonly has been brief and attributed to steroids. We believe that this reversible myasthenic syndrome probably represents neurotoxicity due to high doses of steroidal nondepolarizing blocking agents; however, available data are insufficient to resolve this controversy.     

An electron microscopic study of the neuromuscular junction in the myotomes of larval lamprey, Lampetra japonica.

The neuromuscular junction in the myotomes of larval and adult lampreys, Lampetra japonica, was studied with the electron microscope. In larval lampreys of 26 days after artificial insemination, the myotome consists of triangular lamellae of muscle cell with their bases laterally and apexes medially oriented and placed one on the other. The lateral aspect of the myotome is covered by a layer of flattened cell, and the other aspect is covered by an external lamina which does not extend into the intercellular space between adjacent cells within a myotome. A bundle of thin axons was found in a depression at the middle of medial edge (apex) of each muscle lamella of the myotome and neuromuscular junction was formed here. No nerve endings were found at the myoseptal ends or at the lateral borders of the muscle lamellae. Enlarged axon terminals contained numerous clear vesicles with a few cored vesicles, mitochondria and neurofilaments. The presynaptic axolemma was separated from the postsynaptic sarcolemma by an interspace (50-55 mmu wide) with an interposed external lamina. In the trunk musculature of adult lampreys, nerve endings were found on the surface of the parietal fibers whereas they were seen on both the myoseptal ends near the myotendinous junction along the medial border of each central fiber. Thickening and enhancement in the electron density and accumulation of filamentous material on the sarcoplasmic surface of the postsynaptic sarcolemma were noted in both the larval and adult lampreys. Any other specific alterations were not found on both the pre- and postsynaptic membrane in the neuromuscular junctions of larval and adult lampreys. A brief comment was made on the relationship in development of the characteristic muscle units and patterns of the motor innervation in the larval and adult lampreys. The significance of the neuromuscular junction in the very young larvae reported here was also discussed in respect to the evolution of the neuromuscular junction, particularly in lower chordates, and it was presumed to be the most primitive pattern of innervation in the vertebrate skeletal muscle.     

Weakness on the intensive care unit

Patients who are recovering from critical illness may be weak and difficult to wean from ventilatory support as a complication of their underlying disorder, intercurrent events or treatment given during prolonged intensive care. These patients are difficult to assess because of the severity of their weakness and any accompanying encephalopathy. It is essential to undertake a meticulous review, including assessment of any septic, hypoxic or metabolic derangements and a detailed look at the dosage and duration of medication including antibiotics, neuromuscular junction blocking agents and sedation. If a primary underlying neurological cause or an intercurrent event have been excluded, the likeliest cause of weakness is one of the neuromuscular complications of critical care such as: critical care polyneuropathy, an acute axonal neuropathy which develops in patients with preceding sepsis or multi-organ failure; the use of neuromuscular junction blocking agents or steroids; and critical illness myopathy, which is the most common cause of critical care related weakness.     

Concurrent chronic motor axonal polyneuropathy and synaptic impairment of neuromuscular junction

Polyneuropathies may exhibits clinical, electrophysiologic signs of neuromuscular junction impairment. Distal motor nerve terminals and neuromuscular junction contain pre or postsynaptically specific targets for circulating autoantibodies, if present in neuropathies. Motor nerve terminal blockade either reversible or permanent is a putative factor of muscle weakness. A 59-year-old patient exhibited oropharyngeal, facial, extremity weakness, fluctuating fatigability, and areflexia. Elecectrophysiologic studies showed purely motor axonal polyneuropathy. Thenar, facial slow rate repetitive stimulation revealed up to 47% decrement of compound muscle action potential size. Single fiber electromyography on voluntary activation confirmed increased jitter and impulse blocking in all muscles examined in one third of the fibers. Repeated testings for antibodies to gangliosides, acetylcholine, muscle tyrosine kinase receptors, voltage-gated calcium channels were negative. Oral pyridostigmine bromide improved bulbar symptoms. Pulse intravenous immunoglobulin, oral steroids, and azathioprine had steady benefit. Impairment of neuromuscular transmission if occurring in chronic axonal neuropathies highlights mechanisms and significance of neuromuscular chronic "synaptopathies."     

Effects of cooling and ARL 67156 on synaptic ecto-ATPase activity in guinea pig and mouse vas deferens

We have studied the influence of temperature and ARL 67156 on ATP hydrolysis in mouse and guinea pig vas deferens in order to explore the properties of the enzymatic inactivation mechanism proposed to regulate purinergic neurotransmission at the sympathetic neuromuscular junction of smooth muscle. The ectonucleotidase activity was determined by using the malachite green method to measure the inorganic phosphate (Pi) liberated with ATP used as a substrate. ATP hydrolysis in both species was found to be insensitive to ouabain (100 microM), sodium azide (1 mM), sodium vanadate (100 microM) and beta-glycerophosphate (10 mM) and was also found to depend on Ca2+ and Mg2+. V(MAX) of the ectonucleotidase activity for guinea pig and mouse vas deferens was 958.4+/-66.3 and 79.7+/-8.5 pmol/min/mg, while K(M) was 625.1+/-45.2 and 406.0+/-29.0 microM, respectively. Cooling the tissues from 35 to 25 degrees C reduced the enzyme activity significantly (P<0.01) by 52.7+/-9.2% in guinea pig vas deferens and 34.9+/-5.3% in mouse vas deferens. ARL 67156 (100 microM), the specific ecto-ATPase inhibitor, caused a reduction in enzyme activity in guinea pig and mouse vas of 54.1+/-16.4% and 53.0+/-7.6%, respectively (P<0.01). The degree of inhibition of ATP hydrolysis by lowered temperature and 100 microM ARL 67156 correlates well with the reported potentiation and prolongation of junction potentials under these conditions. It is concluded that ecto-ATPase or a closely related ectonucleotidase plays an important role in the physiological regulation of purinergic neurotransmission.     

Motor potentials evoked by magnetic stimulation of the motor cortex in normal subjects and patients with motor disorders.

Motor evoked potentials (MEPs) elicited by magnetic coil stimulation of motor cortex were studied at rest and during maximum voluntary muscle contraction in 20 normal subjects and 42 patients with motor disorders. MEP parameters employed in this study included: onset latency, amplitude, MEP/M wave amplitude ratio and background EMG/MEP area ratio. Maximum voluntary contraction increased the amplitude of MEPs compared to the size of M waves elicited by peripheral nerve stimulation. A reduced MEP/M wave amplitude ratio had a higher correlation with pyramidal tract involvement than did a prolonged MEP onset latency. Analysis of MEP parameters may help in the differential diagnosis of cerebral infarction, ALS and cervical spondylotic radiculomyelopathy. The inhibitory period which follows MEPs during voluntary contraction was observed in all subjects; the mean duration in normal subjects was 126.6 +/- 29.5 msec. The mean duration of the inhibitory period in patients with cerebral infarction, ALS and cervical spondylotic radiculomyelopathy was 73.9 +/- 41.7 msec, 79.5 +/- 54.5 msec and 85.1 +/- 36.5 msec, respectively. These values were significantly shorter than in normal subjects.     

A new potent channel blocker: Effects on glutamate responses at the crayfish neuromuscular junction

The glutamate blocking action of 5-methyl-1-phenyl-2-(3-piperidinopropylamino)-hexane-1-ol (MLV-5860) was studied at the crayfish neuromuscular junction using electrophysiological techniques. The opener muscle of the dactyl in the first leg of the crayfish was used to examine the action of the drug on the glutamate response. MLV-5860 reduced the amplitude of repetitively-induced glutamate potentials in a dose-dependent manner at the crayfish neuromuscular junction and this reduction was time- and activity-dependent. The minimum effective concentration of MLV-5860 to reduce the glutamate response was estimated to be lower than 50 nM, and therefore MLV-5860 is the most powerful glutamate blocker known at the crayfish neuromuscular junction. Pretreatment of the muscle fiber with concanavalin A did not affect the action of MLV-5860. MLV-5860 reduced the amplitude of excitatory junctional potentials (EJPs) and increased the decay rate of extracellularly-recorded EJPs in a dose-dependent manner. Quisqualate responses were also reduced by this drug but the conductance increase of the muscle membrane induced by GABA was not affected. MLV-5860 did not cause a significant change in the input resistance of the opener muscle fiber at concentrations less than 10 microM. The action of the drug is possibly explained in part by the open channel block of the glutamate-activated ion channels. The forward rate constant for channel blockade was estimated from the difference between the decay rate constants of extracellular EJPs in the absence and presence of the drug and the estimated value was 6.5 +/- 1.4 X 10(7) M-1 s-1.     

Remote F-wave changes after local botulinum toxin application.

OBJECTIVE: Although the therapeutic effects of botulinum toxin A can be explained by its action at the neuromuscular junction, central or more proximal effects have also been discussed. METHODS: Eleven patients with torticollis spasmodicus and 3 patients with writer's cramp were studied before and 1 and 5 weeks after the first treatment with botulinum toxin. We measured compound muscle action potentials (CMAPs), motor conduction velocities (MCVs), the shortest (SFL) and the mean F-wave latencies (MFL) and F-wave persistence (30 trials) of untreated muscles for each side (ulnar nerve-abductor digiti minimi muscle, peroneal nerve-tibialis anterior muscle). RESULTS: CMAPs and MCVs showed no significant changes. For both nerves, however, SFL and MFL were prolonged slightly 1 week after treatment and returned to about baseline after 5 weeks (t test). The F-wave persistence was reduced 1 week after treatment for the right ulnar and both peroneal nerves (t test). CONCLUSIONS: These results are not likely due to an impairment of neuromuscular transmission. Instead, we propose a decreased excitability of alpha-motoneurons supplying non-treated muscles. A reduction of muscle spindle activity or changes of the recurrent inhibition are discussed as possible causes.     

Study on the latency difference between compound muscle and sensory nerve action potentials]

In motor nerve conduction studies compound muscle action potentials (CMAPs) appear later than sensory nerve action potentials (SNAPs). This time lag originates from the conduction delay at the distal motor axon, neuromuscular transmission time and muscle action potential induction time. To investigate the latency difference between CMAPs and SNAPs we studied 46 healthy individuals, 46 patients with diabetes mellitus and 33 patients with carpal tunnel syndrome, using the lumbrical and interossei recording method. In this method the recording active electrode was placed on the 2nd lumbrical muscle and the reference electrode on the proximal palmar aspect of the index finger. Supramaximal stimulation was given to the median or ulnar nerve trunk at 9-cm proximal to the recording active electrode. The CMAP from the 2nd lumbrical muscle (L) and the SNAP from the digital nerve (N) were recorded after median nerve stimulation, and the CMAP from the 2nd interossei muscles (I) was recorded after ulnar nerve stimulation. The residual latency, which is arbitrary defined as the latency difference (L-N) in this study, was 1.38 +/- 0.15 (mean +/- SD) msec in healthy individuals. About 1 msec of the residual latency is regarded as the time for neuromuscular transmission and the time to evoke muscle activities. Thus, the conduction delay at the distal motor axon was calculated as about 0.4 msec in healthy individuals. The residual latency was relatively constant in 29 diabetic patients without conduction delay across the carpal tunnel, which was defined by the latency difference (L-I) < or = 0.4 msec. Their sensory nerve conduction velocities (calculated from N latency) were always above 40 m/sec. On the other hand in diabetic patients with conduction delay across the carpal tunnel, which was defined by the latency difference (L-I) > 0.4 msec, the residual latency gradually increased as the sensory nerve conduction velocity decreased. Their sensory nerve conduction velocities were mostly less than 40 m/sec. The similar relationship was observed in patients with carpal tunnel syndrome without diabetes mellitus. We consider that the diabetic neuropathy alone doesn't cause the increase of the residual latency. Instead, severe conduction delay across the carpal tunnel decreases the N velocity and increases the residual latency. We can also regard the relationship between the latency difference (L-N) and N velocity as being in inverse proportion. Perhaps the increase of the residual latency was simply caused by the proportional decrease in the conduction velocity at the distal motor axon, not by the special mechanism concerning to the carpal tunnel syndrome. This paper presented the electrophysiological changes seen in the distal segment secondary to the proximal entrapment.     

Motor and cortical sensory evoked potentials by magnetic stimulation

Motor evoked potentials (MEP) by magnetic stimulation on the scalp and the spinous processes of the 7th cervical (C 7) and 5th lumbar (L 5) vertebrae were studied in 20 normal subjects and 10 patients with the pyramidal tract lesions. The magnetic stimulator composed of two flat helical coils with mean inner diameters of 12.0 and 2.2 cm. The evoked muscle action potentials were recorded from the thenar muscle in the hand and abductor hallucis muscle in the leg. The mean peak latencies of MEP recorded from the thenar muscle were 22.1 +/- 1.7 and 12.8 +/- 0.9 msec at the stimulations on the scalp and C 7, respectively. The central motor conduction time (CMCT) between the cortex and C 7 was 9.1 +/- 1.1 msec. On the other hand, the peak latencies of MEP were 41.0 +/- 3.2 and 21.6 +/- 2.3 msec at the stimulations on the scalp and L 5, respectively. CMCT between the cortex and L 5 was 19.3 +/- 2.3 msec. The patients with pyramidal tract involvements showed delayed peak latencies or absent MEP. The cortical somatosensory evoked potentials (SEP) by the noninvasive magnetic stimulation on the levels of Th 10, Th 12 and L 5 spines, gluteus and ankle were studied in 20 normal subjects and 7 patients with neurological diseases. Cortical components P 2 and N 2 were recorded clearly in all normal subjects.(ABSTRACT TRUNCATED AT 250 WORDS)     

Single-fiber electromyography for studying the effect of betamethasone on normal neuromuscular junctions in man

The effects of steroids on normal end-plate in vivo were evaluated in man by using single-fiber electromyography (SFEMG). SFEMG was performed on voluntarily activated extensor digitorium communis muscle under basal conditions and 1 week later an intramuscular injection of 4 mg betamethasone per day was administered for 7 days. Ten patients with low back pain were examined. Steroid therapy did not induce any statistically significant variation either of the mean jitter value or of the percentage of recordings with abnormally high jitter. The results of this study do not give evidence of a direct effect of steroids on normal neuromuscular junction.     

Motor potentials of inferior orbicularis oculi muscle to transcranial magnetic stimulation. Comparison with responses to electrical peripheral stimulation of facial nerve.

Magnetic stimulation at the vertex evoked a motor potential (MP) in the inferior orbicularis oculi muscle of 10 healthy subjects with an onset latency of 8-13 msec. Its amplitude increased and its latency decreased when the muscle was contracted: the latency measured 9.5 +/- 1.3 msec with an intensity of stimulation 10-15% above threshold in the contracted muscle. This MP is secondary to excitation of the motor cortex. With the coil placed over the occipital scalp and the same stimulation intensity, an MP was recorded with an onset latency at 4.5 +/- 0.6 msec. This response reflects the activation of the facial nerve root. The peripheral electrical stimulation of the facial nerve at the mandible angle elicited an MP with an onset latency at 3.5 +/- 0.4 msec. Most records showed the presence of late components at about 30 msec for all types of stimulation.     

Glucocorticoid increases acetylcholinesterase and organization of the postsynaptic membrane in innervated cultured human muscle.

We have studied the influence of hydrocortisone (HC) on the neuromuscular junctions (NMJs) established on cultured human muscle fibers that had been innervated by fetal rat spinal cord neurons. Treatment with HC was begun 4 weeks after innervation and continued for 1-28 days. Four weeks of treatment significantly increased (a) size of acetylcholinesterase (AChE)-positive sites, indicative of NMJs; (b) intensity of AChE staining; (c) A12-AChE (junctional) molecular fraction; and (d) organization of junctional postsynaptic folds. The effect of HC depended on the dose and duration of treatment. These effects on the molecular properties of the postsynaptic component of the human neuromuscular junction could be through an action of HC directly on the muscle fiber or indirectly by affecting the motor neuron. Because the increased organization of the postsynaptic folds and the increased AChE seem to be salutory effects on the NMJ of prolonged HC treatment, these changes of the NMJ itself might contribute to the long-term beneficial effect of prednisone, another glucocorticoid, in myasthenia gravis patients.     

GDNF is regulated in an activity-dependent manner in rat skeletal muscle

Glial cell line-derived neurotrophic factor (GDNF) is produced by skeletal muscle and affects peripheral motor neurons. Elevated expression of GDNF in skeletal muscle leads to hyperinnervation of neuromuscular junctions, whereas postnatal administration of GDNF causes synaptic remodeling at the neuromuscular junction. Studies have demonstrated that altered physical activity causes changes in the neuromuscular junction. However, the role played by GDNF in this process in not known. The objective of this study was to determine whether changes in neuromuscular activity cause altered GDNF content in rat skeletal muscle. Following 4 weeks of walk-training on a treadmill, or 2 weeks of hindlimb unloading, soleus, gastrocnemius, and pectoralis major were removed and analyzed for GDNF content by enzyme-linked immunosorbant assay. Results indicated that walk-training is associated with increased GDNF content. Skeletal muscle from hindlimb-unloaded animals showed a decrease in GDNF in soleus and gastrocnemius, and an increase in pectoralis major. The altered production of GDNF may be responsible for activity-dependent remodeling of the neuromuscular junction and may aid in recovery from injury and disease.     

Prolonged paralysis due to nondepolarizing neuromuscular blocking agents and corticosteroids

The long-term use of nondepolarizing neuromuscular blocking agents (ND-NMBA) has recently been implicated as a cause of prolonged muscle weakness, although the site of the lesion and the predisposing factors have been unclear. We report 3 patients (age 37–52 years) with acute respiratory insufficiency who developed prolonged weakness following the discontinuation of ND-NMBAs. Two patients also received intravenous corticosteroids. Renal function was normal but hepatic function was impaired in all patients, and all had acidosis. Electrophysiologic studies revealed low amplitude compound motor action potentials, normal sensory studies, and fibrillations. Repetitive stimulation at 2 Hz showed a decremental response in 2 patients. The serum vecuronium level measured in 1 patient 14 days after the drug had been discontinued was 172 ng/mL. A muscle biopsy in this patient showed loss of thick, myosin filaments. The weakness in these patients is due to pathology at both the neuromuscular junction (most likely due to ND-NMBA) and muscle (most likely due to corticosteroids). Hepatic dysfunction and acidosis are contributing risk factors. © 1994 John Wiley & Sons, Inc.     

THE PERMEABILITY OF THE BASAL LAMINA AT THE NEUROMUSCULAR JUNCTION. AN ULTRASTRUCTURAL STUDY OF RAT SKELETAL MUSCLE USING PARTICULATE TRACERS

Various macromolecular substances, such as toxins and antibodies, may interfere with neuromuscular transmission. The neuromuscular junction is also known to be a site for the uptake of macromolecular substances into the axon for subsequent transport to the central nervous system. The synaptic cleft of the neuromuscular junction is separated from the rest of the extracellular compartment of muscle by the basal lamina, the permeability properties of which are not known. The penetration of macromolecular substances of varying size into the synaptic cleft of the neuromuscular junction has been studied in rats. Four different tracers: Imferon (an iron-dextran measuring 11 X 7 X 7 nm), ferritin (a spherical iron-protein 12 nm in diameter), Imposil (an iron-dextran measuring 21 X 12 X 12 nm) and colloidal gold-protein (20-25 nm in diameter) were injected into the palmaris longus muscle. Fifteen and 120 min after injection, the distribution of these particulate tracers was studied by electron microscopy. Imferon and ferritin penetrated rapidly through the basal lamina along the muscle fibres and also into the synaptic cleft of the neuromuscular junction. The larger Imposil and colloidal gold particles were restricted from penetrating the basal lamina even after 2 h, and these particles were traced only occasionally within the synaptic cleft. The results indicate that the basal lamina of muscle acts as a diffusion barrier to large macromolecules, preventing them from entering the synaptic cleft.     

New evidence for a presynaptic action of prednisolone at neuromuscular junctions

The action of prednisolone at the neuromuscular junction was studied in mouse isolated phrenic nerve-diaphragm and rat external popliteal/sciatic nerve-tibialis anterior muscle preparations. Prednisolone (0.03 mM and 0.3 mM) did not alter the twitch-tension in phrenic nerve-diaphragm preparations after 120 min, but increased the frequency (170 +/- 4%) and amplitude (200 +/- 13%) of miniature end-plate potentials. Quantal content was not influenced by the glucocorticoid treatment. Prednisolone (400 microg/kg) did not change the twitch-tension in rat external popliteal/sciatic nerve-tibialis anterior muscle preparations. However, this steroid (0.3 mM) prevented the neuromuscular blockade by d-tubocurarine (1.45 microM) in mouse preparations by 70 +/- 10% (P < 0.05). A similar effect (82 +/- 6% protection, P < 0.05) occurred in rats treated with prednisolone (400 microg/kg) before d-tubocurarine (225 microg/kg). In phrenic nerve-diaphragm preparations, prednisolone (0.3 mM) increased (13 +/- 4%, p < 0.05) the twitch-tension in the presence of beta-bungarotoxin (1 microM), and prevented the blockade produced by this toxin (0.15 microM) in its third phase of action. This presynaptic facilitatory effect may contribute to the usefulness of prednisolone in myasthenia gravis.     

The relations between long-latency reflexes in hand muscles, somatosensory evoked potentials and transcranial stimulation of motor tracts

In 15 normal subjects the latency of electrically elicited long-latency reflexes (LLRs) of thenar muscles was compared with somatosensory evoked potentials (SEPs) after median nerve stimulation and with the latencies of thenar muscle potentials after transcranial stimulation (TCS) of the motor cortex. Assuming a transcortical reflex pathway the intracortical relay time for the LLR was calculated to be 10.4 +/- 1.9 msec (mean +/- S.D.) or 8.1 +/- 1.6 msec depending on the experimental conditions. The duration of the cortical relay time is not correlated with the peripheral or central conduction times, with body size or arm length. If the LLRs of hand muscles are conducted transcortically the long duration of the cortical relay time suggests a polysynaptic pathway.     

Motor evoked potentials and central motor conduction: studies of transcranial magnetic stimulation with recording from the leg.

To determine central conduction times in the corticospinal pathways of humans using magnetic stimulation, we have developed a method for consistently recording conduction times between the motor cortex and the L4-5 level of the spinal cord. In 30 subjects, motor evoked potentials (MEPs) were recorded from the tibialis anterior muscle following contralateral motor cortex and peroneal nerve stimulation. In 18 of these subjects, the L4-5 intervertebral space was stimulated. The stimuli consisted of single, painless, short-duration magnetic pulses. In 12 subjects, measurements were made during voluntary ankle dorsiflexion, and during vibration of the TA tendon at rest. All subjects had measureable MEP latencies of 30.3 +/- 2.2 msec (mean +/- S.D.). The central motor conduction time (CMCT) was calculated using both a direct as well as an indirect method. The direct method in 18 subjects had a mean value of 16.2 +/- 1.7 msec, while the indirect method in all 30 subjects was 13.8 +/- 1.8 msec. No significant correlation of the CMCT was found with either age or height in these subjects. Ankle dorsiflexion significantly reduced the MEP latency and increased the amplitude, whereas vibration of the TA tendon significantly increased the amplitude alone. We conclude that MEPs may be consistently and painlessly measured in the lower extremity using magnetic stimulation in adults. Facilitation of the MEPs was produced more consistently by voluntary contraction than by vibratory stimulation of the tibialis anterior muscle tendon. Finally, CMCT was independent of both age and height in our study population.