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Background and Purpose: Conduction block is a pathognomonic feature of immune-mediated neuropathies. The aim of this study was to advance understanding of pathophysiology and conduction block in chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN)., Methods: A multimodal approach was used, incorporating clinical phenotyping, neurophysiology, immunohistochemistry and structural assessments., Results: Of 49 CIDP and 14 MMN patients, 25% and 79% had median nerve forearm block, respectively. Clinical scores were similar in CIDP patients with and without block. CIDP patients with median nerve block demonstrated markedly elevated thresholds and greater threshold changes in threshold electrotonus, whilst those without did not differ from healthy controls in electrotonus parameters. In contrast, MMN patients exhibited marked increases in superexcitability. Nerve size was similar in both CIDP groups at the site of axonal excitability. However, CIDP patients with block demonstrated more frequent paranodal serum binding to teased rat nerve fibres. In keeping with these findings, mathematical modelling of nerve excitability recordings in CIDP patients with block support the role of paranodal dysfunction and enhanced leakage of current between the node and internode. In contrast, changes in MMN probably resulted from a reduction in ion channel density along axons., Conclusions: The underlying pathologies in CIDP and MMN are distinct. Conduction block in CIDP is associated with paranodal dysfunction which may be antibody-mediated in a subset of patients. In contrast, MMN is characterized by channel dysfunction downstream from the site of block., (© 2019 EAN.)

Objective: Although autoantibodies targeted against voltage-gated potassium channel (VGKC)-associated proteins have been identified in limbic encephalitis (LE) and acquired neuromyotonia (aNMT), the role of these antibodies in disease pathophysiology has not been elucidated. The present study investigated axonal function across the spectrum of VGKC-complex antibody associated disorders., Methods: Peripheral axonal excitability studies were undertaken in a cohort of patients with LE (N=6) and aNMT (N=11), compared to healthy controls (HC; N=20)., Results: Patients with LE demonstrated prominent abnormalities in peripheral axonal excitability during the acute phase, with reduced threshold change in threshold electrotonus (depolarizing 10-20 LE: 58.5±3.1%; HC: 67.4±0.9%; P<.005; S2 accommodation LE: 17.2±1.4%; HC: 22.2±0.6%; P≤.005) and in recovery cycle parameters (superexcitability LE: -16.0±0.9%; HC: -23.4±1.1%; P<.01; subexcitability LE: 8.5±1.2%; HC: 13.8±0.7%; P≤.005). The pattern of change in LE patients was dissimilar to the effects of antiepileptic medications, suggesting that these factors did not underlie excitability changes in LE. Normalization of excitability parameters was associated with recovery (TEd peak correlation coefficient=.868; P=.002), suggesting that peripheral excitability studies may provide a marker associated with clinical improvement. In contrast, patients with aNMT demonstrated no significant changes at the site of stimulation., Conclusions: The lack of prominent excitability abnormalities in patients with aNMT likely reflects a distal origin of hyperexcitability, expected to be at the motor nerve terminal, while the prominent changes observed in patients with LE likely represent a complex disturbance at the level of the axonal membrane, combined with electrolyte imbalance and adaptive change., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Various factors, including maturity, have been shown to influence peripheral nerve excitability measures, but little is known about differences in these properties between axons with different stimulation thresholds. Multiple nerve excitability tests were performed on the caudal motor axons of immature and mature female rats, recording from tail muscles at three target compound muscle action potential (CMAP) levels: 10%, 40% ("standard" level), and 60% of the maximum CMAP amplitude. Compared to lower target levels, axons at high target levels have the following characteristics: lower strength-duration time constant, less threshold reduction during depolarizing currents and greater threshold increase to hyperpolarizing currents, most notably to long hyperpolarizing currents in mature rats. Threshold-dependent effects on peripheral nerve excitability properties depend on the maturation stage, especially inward rectification (Ih), which becomes inversely related to threshold level. Performing nerve excitability tests at different target levels is useful in understanding the variation in membrane properties between different axons within a nerve. Because of the threshold effects on nerve excitability and the possibility of increased variability between axons and altered electric recruitment order in disease conditions, excitability parameters measured only at the "standard" target level should be interpreted with caution, especially the responses to hyperpolarizing currents., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Non-invasive excitability tests have been developed to appraise axonal membrane properties in peripheral nerves and are contributing to our understanding of neuropathies and neuronopathies. These techniques have been adapted to in vivo and in vitro rat models, but little data are available on mice, although mice provide more transgenic models of neurological disorders. This study was therefore undertaken to assess the suitability of mice to model human nerve excitability measurements and to document changes during maturation. Female mice, aged 4-19 weeks, were recorded under isoflurane anesthesia. Electrical stimuli were applied via surface electrodes to the caudal motor nerve and compound muscle action potentials (CMAPs) recorded from the tail with needle electrodes. Then, the sciatic nerve was stimulated above the ankle and CMAPs recorded from plantar muscles. The method was only minimally invasive, enabling the same animal to be tested up to eight times at weekly intervals. As in human studies, the multiple excitability program recorded stimulus-response, strength-duration, and current-threshold relationships; threshold electrotonus; and recovery cycle. The response waveforms were qualitatively similar to those from human axons. This resemblance was closer for the caudal nerve, which also showed more marked changes with age. Early hyperpolarizing electrotonus fell sharply from weeks 4 to 13 (p < 0.0001), while a progressive increase in superexcitability occurred throughout the period studied (p < 0.001). We conclude that multiple measures of nerve excitability can be performed reliably in mice in vivo, preferentially on the tail, and are suitable for longitudinal studies, but age matching is critical for younger animals.

Threshold electrotonus involves tracking the changes in axonal excitability produced by subthreshold polarizing currents and is the only technique that allows insight into the function of internodal conductances in human subjects in vivo. There is often an abrupt transient reversal of the threshold change as excitability increases in response to conditioning depolarizing currents (S1 phase). In recordings from motor axons, it has been recently demonstrated that this notch or inflection is due to activation of low-threshold axons. We report that a notch is frequently seen in sensory recordings (in 33 of 50 healthy subjects) using the standard threshold electrotonus protocol. When large, the notch can distort subsequent phases of threshold electrotonus and could complicate quantitative measurements and modeling studies.

Excitability measurements on human motor and sensory nerves have provided new insights into axonal membrane changes in peripheral nerve disorders. The aim of this study was to establish an in vivo rat preparation suitable for threshold tracking of sensory nerve action potentials (SNAPs) to model clinical sensory nerve excitability studies. In Sprague-Dawley rats anesthetized with ketamine and xylazine, current stimuli were applied to the base of the tail and SNAPs recorded from distal needle electrodes. Multiple excitability data were obtained as previously described for human nerves and compared to recordings from the motor tail axons and to sensory recordings from human median and ulnar nerves. The pattern of excitability changes in rats was broadly similar to that in humans, although some parameters differed significantly. Individual recordings were stable for at least 3 h. These data show that the rat tail enables excitability properties of sensory as well as motor axons to be studied experimentally, e.g., in models of nerve disease and during pharmacological interventions.

The pathophysiology of hepatic neuropathy is poorly understood, but membrane depolarization due to a toxic inhibition of oxidative metabolism has been proposed. We investigated the relationship between nerve excitability properties, nerve dysfunction, and liver function in 11 pretransplant patients, the majority of whom were oligo- or asymptomatic for peripheral neuropathy. Abnormalities were detected on clinical examination (6), large-fiber nerve conduction (4), and thermal quantitative sensory testing (10). Small-fiber involvement was characterized by elevation of warm more than cold detection thresholds. Autonomic dysfunction was less frequent (4). Nerve excitability parameters in both upper and lower limbs provided evidence of membrane depolarization compared with controls, even in those patients without a history of alcohol abuse. No clear correlation was found between neurophysiological indices and scores of hepatic reserve or various blood parameters including ammonia level. Although chronic membrane depolarization may be involved, the degree of depolarization in large fibers was small, and its role in the pathophysiology of neuropathy uncertain.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is characterized by multifocal demyelination along the course of the nerves, and involvement of the intermediate segments may correlate with more severe demyelination associated with breakdown of the blood-nerve barrier. Threshold electrotonus was used to study whether altered membrane properties of the median nerve at the wrist (intermediate segment) are associated with clinical profiles in 21 CIDP patients. In response to hyperpolarizing conditioning stimuli, the threshold changes were significantly greater for CIDP patients than for normal controls (n = 49). The pattern was similar to that of 11 patients with Charcot-Marie-Tooth disease type 1a, who exhibited abnormally high thresholds to hyperpolarizing currents. The abnormal threshold electrotonus was present in 48% of the CIDP patients and was associated with longer disease duration, more severe disability, poorer response to immune treatments, and slower nerve conduction velocities. Threshold electrotonus can be used to detect demyelination at the tested sites and may provide new information about pathophysiology and distribution patterns of demyelination in CIDP.

Multiple nerve excitability measurements were used to investigate axonal membrane properties of patients diagnosed with multifocal motor neuropathy (MMN). Six patients were selected, all with evidence of distal focal motor conduction block involving the median nerve in the forearm. In all patients, the median nerve was stimulated at the wrist, just distal to the site of block, and the resulting compound muscle action potentials were recorded from abductor pollicis brevis. Stimulus-response behaviour, the strength--duration time constant, threshold electrotonus to 100 ms polarizing currents, a current-threshold relationship and the recovery of excitability following supramaximal activation were recorded using a protocol described recently. When compared with control values, patients demonstrated significantly greater superexcitability, a 'fanning out' of threshold electrotonus recordings, and a significant change in the slope of the current--threshold relationship. These abnormalities in axonal membrane excitability parameters closely resembled those in normal axons hyperpolarized following release from ischaemia. To test for axonal hyperpolarization, DC depolarizing currents were applied to the nerves of three patients, and all the excitability parameters were normalized by depolarization. Attempts to trace excitability measures proximally towards the site of block were unsuccessful, as the nerve became inexcitable in all cases. It is suggested that the distal hyperpolarization is probably linked to focal depolarization and that the clinical features of MMN are consistent with a depolarizing/hyperpolarizing lesion.

In order to explore the pathophysiology of diabetic neuropathy, we studied serial changes of axonal excitability in 20 adult Wistar rats with streptozocin-induced diabetes using the technique of threshold electrotonus (TE). After persistent hyperglycaemia had developed, rats were divided into two groups: nine were fed a diet containing aldose reductase inhibitor (Epalrestat 30 mg/kg/day) (ARI(+) group) and 11 were fed a diet without the inhibitor (ARI(-) group). Eight normal control rats of similar age (NC group) were also studied. We monitored membrane properties of motor axons in the tail for 3 months using TE to measure the changes in excitability induced by subthreshold polarizing currents while recording compound muscle action potentials (CMAPs) in the tail muscle. The ARI(-) group showed a significant increase in CMAP latency 1 month after streptozocin injection, and by 3 months there was significantly lower excitability after hyperpolarization for 100 ms compared with the NC group. A similar change in TE was reproduced by injection of caesium chloride, an inhibitor of inward rectification. By contrast, the ARI(+) group exhibited no significant change in TE or latency at 3 months, although they showed significant body weight loss and hyperglycaemia. These findings indicate that inward rectification is reduced in an experimental model, as in human diabetes, and that blocking the polyol pathway with an ARI prevents this reduction. Reduced inward rectification potentiates conduction block caused by activity-dependent hyperpolarization and may underlie the decreased vibratory sensation seen in the early stage of diabetic neuropathy.

Conventional electrophysiological tests of nerve function focus on the number of conducting fibers and their conduction velocity. These tests are sensitive to the integrity of the myelin sheath, but provide little information about the axonal membrane. Threshold tracking techniques, in contrast, test nerve excitability, which depends on the membrane properties of the axons at the site of stimulation. These methods are sensitive to membrane potential, and to changes in membrane potential caused by activation of ion channels and electrogenic ion pumps, including those under the myelin sheath. This review describes the range of threshold tracking techniques that have been developed for the study of human nerves in vivo: resting threshold is compared with the threshold altered by a change in environment (e.g., ischemia), by a preceding single impulse (e.g., refractoriness, superexcitability) or impulse train, or by a subthreshold current (e.g., threshold electrotonus). Few clinical studies have been reported so far, mainly in diabetic neuropathy and motor neuron disease. Threshold measurements seem well suited for studies of metabolic and toxic neuropathies but insensitive to demyelination. Until suitable equipment becomes more widely available, their full potential is unlikely to be realized.

1. The time constants of motor and sensory nerve fibres were studied in normal human ulnar nerves by the method of latent addition, using threshold tracking to follow the recovery of excitability after brief conditioning current pulses. The 60 microseconds test and conditioning stimuli were applied at the wrist, and the conditioning stimuli were set to 90, 60, 30, -30, -60 and -90% of the control threshold current. Compound muscle action potentials were recorded from abductor digiti minimi, and sensory nerve action potentials from the little finger. 2. Recovery from depolarizing conditioning pulses was slower than recovery from hyperpolarizing pulses and strongly dependent on conditioning pulse amplitude. The voltage dependence of latent addition was attributed to subthreshold activation of sodium channels (local response). 3. Motor and sensory nerve excitability generally recovered from -90% hyperpolarizing pulses as the sum of two exponential components, although the slow component was negligible in some motor nerves. The fast component (time constant 43.3 +/- 2.0 microseconds, mean +/- S.E.M., n = 9) was similar between motor and sensory fibres in the same subject. It showed no consistent voltage dependence, and was attributed to a passive input time constant of the fibres. The slow component of recovery from hyperpolarizing pulses was greater in sensory than in motor fibres and was voltage dependent: it could be greatly increased in motor and sensory fibres by steady depolarization. It was attributed to a regenerative membrane current, active at the resting potential in sensory and at least some motor nerves. 4. The latent addition responses were compared with the computed responses of four theoretical models. Both motor and sensory responses were well fitted by a model in which a fraction of the sodium channels (less in motor than in sensory fibres) were activated at potentials 20 mV more negative than normal and at half the normal rate, and did not inactivate. 5. It is concluded that the differences in latent addition between motor and sensory fibres are primarily due to differences in non-classical, voltage-dependent ion channels, active close to the resting potential. These "threshold channels' may help to account for the longer strength-duration time constant of sensory fibres, for their lower rheobase, and for their greater tendency to fire repetitively.

The changes in excitability and supernormality of sensory and motor axons of the median (or ulnar) nerve were tracked during and following ischaemia at the wrist for periods of 5-20 min in normal human volunteers. Supernormality was defined as the fractional increase in excitability produced by a maximal conditioning stimulus, 10 ms before the test stimulus. With relatively brief periods of ischaemia (< 10 min), sensory and motor axons behaved similarly, with an increase in excitability (producing a decrease in threshold) and a decrease in supernormality during ischaemia and a long-lasting decrease in excitability (and increase in supernormality) following release of ischaemia. Most subjects reported paraesthesiae during brief periods of ischaemia but not after its release. No one experienced fasciculation. The threshold changes were generally similar during longer periods of ischaemia, but in the post-ischaemic phase the behaviour of sensory and motor axons diverged. After a rapid post-ischaemic increase, the threshold of sensory axons decreased, approaching the pre-ischaemic level, before rising again and then slowly returning to the control level. Sensory axons of different threshold behaved in a qualitatively similar manner, with no evidence of a bimodal distribution of thresholds in the post-ischaemic phase (as occurs with motor axons when the ischaemia is sufficient to produce fasciculation; see Bostock et al. J. Physiol (Lond) 1991; 441: 537-57). The 'notch' on the threshold plot for sensory axons lasted 20-40 min and was accompanied by a relatively small but appropriate change in supernormality. No such 'notch' was seen with motor axons. The changes in latency were generally similar for sensory and motor axons, largely paralleling the supernormality plots, except at the time of the 'notch'. To test the hypothesis that the differences in behaviour of sensory and motor axons resulted from differences in inward rectification activated by hyperpolarization, the changes in threshold produced by long-lasting (300 ms) depolarizing and hyperpolarizing current pulses were compared for sensory and motor axons. In seven of eight subjects, there was evidence of more inward rectification in sensory axons. In the eighth subject, motor axons behaved similarly to sensory axons. It is concluded that a difference in inward rectification contributes to but is insufficient by itself to account for the differences in behaviour of sensory and motor axons and that the greater propensity of sensor y axons to discharge ectopically cannot be attributed to a single factor.

1. Until now, no direct electrophysiological information has been available on the molecular basis of human nerve excitability. We here report patch-clamp recordings, both single- and multichannel, from acutely dissociated human axons. 2. Voltage-dependent sodium channels with a conductance gamma = 13 pS (measured in Ringer at room temperature) are found in the nodal area. 3. There are several types of voltage-dependent potassium channels: I channels (gamma = 34 pS), F channels (gamma = 50 pS), and channels with small conductance (gamma = 7-9 pS, all measured in high potassium solution). Most of them are closely similar to those already reported in Xenopus and rat axons; in addition a 200-pS, calcium-dependent potassium channel, similar to that in Xenopus, is present. 4. Differences between the electrical behavior of human axons and those of other species are probably not due to the presence of fundamentally different channel types, but may be due to differences in channel density or distribution. 5. As well as increasing our understanding of the basis of excitability in human nerve, this method may prove useful in the investigation of inherited and other human neuropathies.

An early abnormality in the peripheral nerves of patients with diabetes mellitus is that it takes a long period of limb ischaemia to block conduction. As a diagnostic test, however, the procedure is time consuming (30 min of ischaemia). We have now used an electronic feedback system to track threshold changes in human motor axons during and after a short period of ischemia (10 min) induced by a pressure cuff. The strength of stimulus current applied over an appropriate nerve was adjusted to maintain a constant amplitude of muscle action potential. This method reveals an increase in excitability during the first few minutes of ischaemia, and a post-ischaemic depression. Both changes in excitability were consistently much reduced in diabetic subjects compared with normal controls.