An Acute Randomized Controlled Trial of Noninvasive Peripheral Nerve Stimulation in Essential Tremor.

OBJECTIVE: To evaluate the safety and effectiveness of a wrist-worn peripheral nerve stimulation device in patients with essential tremor (ET) in a single in-office session. METHODS: This was a randomized controlled study of 77 ET patients who received either treatment stimulation (N = 40) or sham stimulation (N = 37) on the wrist of the hand with more severe tremor. Tremor was evaluated before and immediately after the end of a single 40-minute stimulation session. The primary endpoint compared spiral drawing in the stimulated hand using the Tremor Research Group Essential Tremor Rating Assessment Scale (TETRAS) Archimedes spiral scores in treatment and sham groups. Additional endpoints included TETRAS upper limb tremor scores, subject-rated tasks from the Bain and Findley activities of daily living (ADL) scale before and after stimulation as well as clinical global impression-improvement (CGI-I) rating after stimulation. RESULTS: Subjects who received peripheral nerve stimulation did not show significantly larger improvement in the Archimedes spiral task compared to sham but did show significantly greater improvement in upper limb TETRAS tremor scores (p = 0.017) compared to sham. Subject-rated improvements in ADLs were significantly greater with treatment (49% reduction) than with sham (27% reduction; p = 0.001). A greater percentage of ET patients (88%) reported improvement in the stimulation group as compared to the sham group (62%) according to CGI-I ratings (p = 0.019). No significant adverse events were reported; 3% of subjects experienced mild adverse events. CONCLUSIONS: Peripheral nerve stimulation in ET may provide a safe, well-tolerated, and effective treatment for transient relief of hand tremor symptoms.

The modulation of force steadiness by electrical nerve stimulation applied to the wrist extensors differs for young and older adults.

PURPOSE: We compared the modulation of force steadiness by different types of electrical nerve stimulation in young (n = 13, 25 ± 4 years) and older (n = 12, 78 ± 5 years) adults. METHODS: The protocol involved four types of isometric contractions with the wrist-extensor muscles at 10% of the maximal force. Three of the contractions involved electrical nerve stimulation that comprised two forms of neuromuscular electrical stimulation (NMES) to evoke muscle contractions and a voluntary contraction with superimposed transcutaneous electrical nerve stimulation (TENS) at an intensity less than motor threshold. RESULTS: The coefficient of variation (CV) for force during voluntary wrist extension was less (P = 0.03) for young (1.82 ± 0.43%) than older adults (2.80 ± 1.08%). The CV for force did not differ between age groups during the three types of electrical nerve stimulation but was reduced relative to the value observed during voluntary wrist extension for older adults. In contrast, the CV for force increased during the voluntary contraction with superimposed TENS for young adults but not for older adults. Moreover, there were significant negative correlations in older adults between the CV for force during the voluntary contraction and its decrease with electrical nerve stimulation. CONCLUSION: Differences in the CV for force between the evoked and voluntary contractions for the two age groups suggest that the variance in common synaptic input to motor neurons during steady voluntary contractions with the wrist extensors is greater for older adults than young adults.

Temporal and Spatial Variability of Surface Motor Activation Zones in Hemiplegic Patients During Functional Electrical Stimulation Therapy Sessions.

The goal of this study was to investigate surface motor activation zones and their temporal variability using an advanced multi-pad functional electrical stimulation system. With this system motor responses are elicited through concurrent activation of electrode matrix pads collectively termed "virtual electrodes" (VEs) with appropriate stimulation parameters. We observed VEs used to produce selective wrist, finger, and thumb extension movements in 20 therapy sessions of 12 hemiplegic stroke patients. The VEs which produce these three selective movements were created manually on the ergonomic multi-pad electrode by experienced clinicians based on visual inspection of the muscle responses. Individual results indicated that changes in VE configuration were required each session for all patients and that overlap in joint movements was evident between some VEs. However, by analyzing group data, we defined the probability distribution over the electrode surface for the three VEs of interest. Furthermore, through Bayesian logic we obtained preferred stimulation zones that are in accordance with our previously reported heuristically obtained results. We have also analyzed the number of active pads and stimulation amplitudes for these three VEs. Presented results provide a basis for an automated electrode calibration algorithm built on a priori knowledge or the starting point for manual selection of stimulation points.

Essential regional nerve blocks for the dermatologist: Part 2.

Following on from Part 1 of the series (regional nerve blocks for the face and scalp), we guide the clinician through the anatomy and cutaneous innervation of the digits, wrist and ankle, providing a practical step-by-step guide to regional nerve blockade of these areas.

Thalamic physiology of intentional essential tremor is more like cerebellar tremor than postural essential tremor.

The neuronal physiological correlates of clinical heterogeneity in human essential tremor are unknown. We now test the hypothesis that thalamic neuronal and EMG activities during intention essential tremor are similar to those of the intention tremor which is characteristic of cerebellar lesions. Thalamic neuronal firing was studied in a cerebellar relay nucleus (ventral intermediate, Vim) and in a pallidal relay nucleus (ventral oral posterior, Vop) during stereotactic surgery for the treatment of tremor. Nine patients with essential tremor were divided clinically into two categories: one with a substantial component of tremor with intention (termed intention ET) and the other without (postural ET). These types of essential tremor were compared with patients having intention tremor plus other clinical signs of cerebellar disease (cerebellar tremor). Neurons in patients with either intention ET or cerebellar tremor had lower firing rates and lower spike×EMG coherence than those in patients with postural ET. Patients with intention ET had a lower spike×EMG phase lead than those with postural ET. Overall, thalamic activity measures of intention ET were different from postural ET but not apparently different from those of cerebellar tremor. One patient with the intention ET (number 4) had a good response to a left thalamotomy and then suffered a right cerebellar hemispheric infarct five years later. After the stroke the intention ET recurred, which is consistent with our hypothesis that intention ET is similar to that of the intention tremor which is characteristic of cerebellar lesions.

Kinematics fingerprints of leader and follower role-taking during cooperative joint actions.

Performing online complementary motor adjustments is quintessential to joint actions since it allows interacting people to coordinate efficiently and achieve a common goal. We sought to determine whether, during dyadic interactions, signaling strategies and simulative processes are differentially implemented on the basis of the interactional role played by each partner. To this aim, we recorded the kinematics of the right hand of pairs of individuals who were asked to grasp as synchronously as possible a bottle-shaped object according to an imitative or complementary action schedule. Task requirements implied an asymmetric role assignment so that participants performed the task acting either as (1) Leader (i.e., receiving auditory information regarding the goal of the task with indications about where to grasp the object) or (2) Follower (i.e., receiving instructions to coordinate their movements with their partner's by performing imitative or complementary actions). Results showed that, when acting as Leader, participants used signaling strategies to enhance the predictability of their movements. In particular, they selectively emphasized kinematic parameters and reduced movement variability to provide the partner with implicit cues regarding the action to be jointly performed. Thus, Leaders make their movements more "communicative" even when not explicitly instructed to do so. Moreover, only when acting in the role of Follower did participants tend to imitate the Leader, even in complementary actions where imitation is detrimental to joint performance. Our results show that mimicking and signaling are implemented in joint actions according to the interactional role of the agent, which in turn is reflected in the kinematics of each partner.

Home-based nerve stimulation to enhance effects of motor training in patients in the chronic phase after stroke: a proof-of-principle study.

BACKGROUND: Somatosensory stimulation in the form of repetitive peripheral nerve stimulation (RPSS) is a promising strategy to improve motor function of the upper limb in chronic stroke. Home-based RPSS may be an alternative to hospital-based RPSS. OBJECTIVES: To investigate the feasibility and safety of an innovative program of home-based RPSS combined with motor training and to collect preliminary data on the efficacy of this program to enhance hand motor function in patients in the chronic phase after stroke. METHODS: Twenty patients were randomized to either active or sham RPSS associated with daily motor training performed at home over 4 consecutive weeks. All the patients were able to perform tasks of the Jebsen-Taylor Test (JTT). The primary outcome measures were feasibility, evaluated by self-reported compliance with the intervention, and safety (adverse events). Secondary outcomes comprised improvements in hand function in the JTT after end of treatment and after a 4-month follow-up period. RESULTS: There were no relevant adverse events. Compliance with RPSS and motor training was significantly greater in the active group than in the sham group. Upper extremity performance improved significantly more in the active group compared with the sham group at the end of treatment. This difference remained significant 4 months later, even when differences in compliance with motor training were considered. CONCLUSIONS: Home-based active RPSS associated with motor training was feasible, was safe, and led to long-lasting enhancement of paretic arm performance in the chronic phase after stroke for those who can perform the JTT. These results point to the need for an efficacy trial.

An investigation into the magnitude of the current window and perception of transcutaneous electrical nerve stimulation (TENS) sensation at various frequencies and body sites in healthy human participants.

INTRODUCTION: Strong nonpainful transcutaneous electrical nerve stimulation (TENS) is prerequisite to a successful analgesic outcome although the ease with which this sensation is achieved is likely to depend on the magnitude of current amplitude (mA) between sensory detection threshold (SDT) and pain threshold, that is, the current window. OBJECTIVES: To measure the current window and participant's perception of the comfort of the TENS sensation at different body sites. METHODS: A repeated measure cross-over study was conducted using 30 healthy adult volunteers. Current amplitudes (mA) of TENS [2 pulses per second (pps); 30 pps; 80 pps] at SDT, pain threshold, and strong nonpainful intensities were measured at the tibia (bone), knee joint (connective tissue), lower back [paraspinal (skeletal) muscle], volar surface of forearm (nerve) and waist (fat). The amplitude to achieve a strong nonpainful intensity was represented as a percentage of the current window. Data were analyzed using repeated measures analysis of variance. RESULTS: Effects were detected for body site and frequency for SDT (P<0.001, P=0.018, respectively), current window (P<0.001, P<0.001, respectively), and strong nonpainful TENS as a percentage of the current window (P=0.002, P<0.001, respectively). The current window was larger for the knee joint compared with tibia (difference [95% confidence interval]=12.76 mA [4.25, 21.28]; P=0.001) and forearm (10.33 mA [2.62, 18.40]; P=0.006), and for the lower back compared with tibia (12.10 mA [1.65, 22.52]; P=0.015) and forearm (9.65 mA [1.06, 18.24]; P=0.019). The current window was larger for 2 pps compared with 30 pps (P<0.001) and 80 pps (P<0.001). Participants rated strong nonpainful TENS as most comfortable at the lower back (P<0.001) and least comfortable at the tibia and forearm (P<0.001). CONCLUSIONS: TENS is most comfortable and easiest to titrate to a strong nonpainful intensity when applied over areas of muscle and soft tissue.

First permanent implant of nerve stimulation leads activated by surface electrodes, enabling hand grasp and release: the stimulus router neuroprosthesis.

BACKGROUND: . More than 150 000 neuroprostheses (NPs) have been implanted in people to restore bodily function in a variety of neural disorders. The authors developed a novel NP, the Stimulus Router System (SRS), in which only passive leads are implanted. Each lead picks up a portion of the current delivered through the skin by an external stimulator. OBJECTIVE: . The authors report on the first human implant of an SRS. METHODS: . The recipient was a tetraplegic man with bilateral hand paralysis. Three SRS leads were implanted in his right forearm to activate the finger extensors, finger flexors, and thumb flexor. A wristlet containing a surface stimulator and electrodes was used to pass trains of electrical pulses through the skin to each lead. Hand opening and grasp were controlled via a wireless earpiece that sensed small tooth-clicks and transmitted signals to the wristlet. RESULTS: . The current required to activate the muscles was less than half that required prior to implantation and below perceptual threshold. Maximal grip force and hand opening aperture were both larger using the SRS. The implanted leads have remained functional for 3 years. The recipient reported various tasks of daily life that improved during SRS usage. An electronic counter revealed mean monthly usage of 18.5 hours, equivalent to 55 hours of continuous manual activity. CONCLUSIONS: . This first implant of the SRS indicates that it can be effective and reliable and has potential to provide an alternative to existing NPs.

Effects of integrated volitional control electrical stimulation (IVES) on upper extremity function in chronic stroke.

We evaluated the efficacy of a novel electromyogram (EMG)-controlled electrical stimulation system, called the integrated volitional control electrical stimulator (IVES), on the recovery of upper extremity motor functions in patients with chronic hemiparetic stroke. Ten participants in the chronic stage (more than 12 months post-stroke with partial paralysis of their wrist and fingers) received treatment with IVES to the extensor carpi radialis and extensor digitorum communis 6 h/day for 5 days. Before and after the intervention, participants were assessed using upper-extremity Fugl-Meyer motor assessment (FMA), the active range of motion (A-ROM), the nine-hole peg test (NHPT), and surface EMG recordings. The upper extremity FMA showed a statistically significant increase from 50.8 ± 5.8 to 56.8 ± 6.2 after the intervention (P < 0.01). The A-ROM of wrist extension was also significantly improved from 36.0° ± 15.4° to 45.0° ± 15.5° (P < 0.01). The NHPT significantly decreased from 85.3 ± 52.0 to 63.3 ± 29.7 (P = 0.04). EMG measurements demonstrated statistically significant improvements in the coactivation ratios for the wrist flexor and extensor muscles after the intervention. This study suggested that 5 days of IVES treatment yields a noticeable improvement in upper extremity motor functions in patients with chronic hemiparetic stroke.

Hebbian-type stimulation during robot-assisted training in patients with stroke.

BACKGROUND: Training-related improvements in motor function are associated with changes in movement representation of the primary motor cortex (M1). In healthy individuals, transcranial magnetic stimulation (TMS) of M1 delivered in a strict temporal relationship (Hebbian-type stimulation) during execution of movements enhances these effects and is superior to random stimulation. OBJECTIVE: The authors tested whether training combined with Hebbian-type M1 stimulation enhances M1 reorganization in patients with stroke. METHODS: Six patients with chronic stroke participated in the study. Patients executed robot-assisted wrist extension movements at 0.2 Hz frequency while subthreshold repetitive TMS was applied over M1 in a strict temporal relationship to the training movements. TMS was applied to either the affected hemisphere (contralateral M1) or the nonaffected hemisphere (ipsilateral M1) at 0.1 Hz. Intervention-related changes in motor maps and intracortical excitability were measured using TMS. RESULTS: Training alone or combined Hebbian-type stimulation of either M1 resulted in differential effects on motor maps and intracortical inhibition. Shifts in motor maps were associated with increases in intracortical excitability. In contrast to previous results for healthy participants, the inhibitory effect of ipsilateral M1 Hebbian-type stimulation was not present, and the facilitatory effect of contralateral M1 stimulation was more subtle. CONCLUSIONS: Hebbian-type stimulation is feasible in patients poststroke and induces map reorganization and associated decreases in GABAergic inhibition. However, because TMS protocols have a different effect on motor reorganization in the injured brain and may depend on location of the lesion, protocols need to be tailored to the patient's pathology.

Changes of excitability in M1 induced by neuromuscular electrical stimulation differ between presence and absence of voluntary drive.

The aim of this study is to investigate excitability changes in the human motor cortex induced by variable therapeutic electrical stimulations (TESs) with or without voluntary drive. We recorded motor-evoked potentials (MEPs) from extensor and flexor carpi radialis (FCR) muscles at rest and during FCR muscle contraction after the application of TES on FCR. TES application conditions were changed intensities, frequencies, and trains. In addition, to evaluate the contribution of M1 inhibitory circuits to the effects of TES application, we also recorded MEPs using paired-pulse transcranial magnetic stimulation. In resting muscle states, an increase in TES intensity resulted in an increase in MEP ratio in both the muscles. In contrast, when TES was applied to FCR during contraction, MEP ratios of both the muscles decreased with increased number of pulse trains. However, under both the states, MEP ratios decreased induced by paired-pulse transcranial magnetic stimulation in extensor carpi radialis to which TES was not applied. Excitability changes in M1 induced by TES application were reversibly modulated depending on the presence or absence of voluntary drive. This study showed that the therapy and the voluntary drive of the target muscles act together, and complement the effects of each other, which may be beneficial for optimizing the rehabilitation if the therapy accompanies voluntary drive.

TENS is harmful in primary writing tremor.

OBJECTIVE: It is unclear whether primary writing tremor (PWT) is a tremulous form of dystonia or a tremor per se. Transcutaneous electrical nerve stimulation (TENS) at 50 Hz applied for 2 weeks was reported to improve the writing capabilities of patients with writer's cramp (WC). We explored whether such a beneficial effect can be obtained in patients with a PWT. METHODS: In a cross-over, double-blinded randomized study we tested whether 2-week periods of 5, 25 or 50 Hz TENS applied to wrist flexor muscles, improved the score of the Fahn-Tolosa-Marin scale of nine patients with PWT. Excitability of neurons and of various intracortical circuits in the motor cortex were also tested before and after TENS by using transcranial magnetic stimulation. RESULTS: TENS at 5 and 25 Hz did not have any effect while TENS at 50 Hz worsened the clinical condition and the cortical excitability. CONCLUSIONS: TENS is not a new treatment alternative for PWT. SIGNIFICANCE: The beneficial effect in WC and the harmful one in PWT of TENS stresses that the two disorders are likely different nosological entities.

Effects of wrist tendon vibration on targeted upper-arm movements in poststroke hemiparesis.

BACKGROUND: Impaired motor control of the upper extremity after stroke may be related to lost sensory, motor, and integrative functions of the brain. Artificial activation of sensory afferents might improve control of movement by adding excitatory drive to sensorimotor control structures. The authors evaluated the effect of wrist tendon vibration (TV) on paretic upper-arm stability during point-to-point planar movements. METHODS: TV (70 Hz) was applied to the forearm wrist musculature of 10 hemiparetic stroke patients as they made center-out planar arm movements. End-point stability, muscle activity, and grip pressure were compared as patients stabilized at the target position for trials completed before, during, and after the application of the vibratory stimulus. RESULTS: Prior to vibration, hand position fluctuated as participants attempted to maintain the hand at the target after movement termination. TV improved arm stability, as evidenced by decreased magnitude of hand tangential velocity at the target. Improved stability was accompanied by a decrease in muscle activity throughout the arm as well as a mean decrease in grip pressure. CONCLUSIONS: These results suggest that vibratory stimulation of the distal wrist musculature enhances stability of the proximal arm and can be studied further as a mode for improving end-point stability during reaching in hemiparetic patients.

Diagnosis and treatment of posterior interosseous nerve syndrome using soft tissue manipulation therapy: a case study.

SUMMARY: Peripheral nerve entrapments of the upper and lower extremity are commonly seen in practice. Chronically repetitive movement patterns lead to constriction of the nerve due to the development of local fibrosis within the soft tissues surrounding the nerve which also affects nerve traction, mobility, and function. A case is presented of a patient with motor weakness in the wrist and hand in order to illustrate the diagnosis and treatment of posterior interosseous nerve (PIN) syndrome. Using Active Release Techniques Soft Tissue Management and Peripheral Nerve Release Systems) the patient's symptomatology was resolved. Soft tissue-based management in conjunction with neural gliding may be beneficial in the conservative management of PIN syndrome. Further research into the pathophysiology of nerve entrapments will have immediate impact on the management of neuropathies and likely result in emphasizing conservative management and rehabilitation rather than surgical intervention particularly in cases not involving denervation or paralysis.

Comments on 'the discrepancy between human peripheral nerve chronaxie times as measured using magnetic and electric field stimuli: the relevance to MRI gradient coil safety'.

A recent electrostimulation study with human subjects (Recoskie et al 2009 Phys. Med. Biol. 54 5965-79) reported a large difference between chronaxie times when stimuli were delivered to the same body locus (the wrist) either through contact electrodes (electric stimulation) or through a pulsed magnetic field (magnetic stimulation). This paper reviews the procedures and analytic methods used in that study that might account for the reported discrepancies. Factors possibly accounting for reported discrepancies include the maximum and minimum pulse widths of the experimental stimuli; variations in experimental waveforms vis-à-vis mathematically ideal functions; differences in the spatial distribution of the in situ electric field for the two methods of delivery and differences in derived chronaxie relative to strength-duration time constants.

Evaluation and treatment of wrist drop in a patient due to lead poisoning: case report.

Lead (Pb) is widely used because of its useful properties and it is ubiquitous in human environment. There are various lead based industries and several workers who are working in these industries without the knowledge of the ill effects of lead and hence not taking proper precautions while handling lead. Many a times, these workers who have accumulated lead in their blood and body organs, are not properly diagnosed and might receive only symptomatic treatment. We describe a thirty-two-year old male, who was working in an unorganized lead based industry for 3 yr, developed severe lead poisoning leading to wrist drop. Since one year the patient received only symptomatic treatment for abdominal pain. His laboratory investigation showed elevated blood lead levels. The chelation therapy using D-Penicillamine brought down his blood lead levels and is on follow up presently. It is required to take proper history about the occupation of the patient, exposed to potentially hazardous levels of lead in the workplace and medically evaluate them.

The startle reaction to somatosensory inputs: different response pattern to stimuli of upper and lower limbs.

Unexpected sensory inputs can generate a patterned startle reaction, aimed at protection and defense. Experimentally, it is usually triggered by auditory stimuli while the startle reaction to somatosensory inputs (SSS) has not received much attention so far. This may be in part due to the fact that somatosensory inputs inevitably cause local reactions, such as short and long latency reflexes and withdrawal reactions, which could interfere with recognition of the startle-related activity. Therefore, we have undertaken a study aimed at separating the SSS from other responses by exploring the responses that are common to somatosensory stimuli applied to different sites and examining the inhibitory effects of prepulse stimuli. In 13 healthy naive subjects, we applied electrical stimuli to the median nerve at the wrist (MW) or the posterior tibial nerve at the ankle (PT) and recorded from orbicularis oculi (OOC), masseter (MAS), sternocleidomastoid (SCM) and representative muscles of the limbs being stimulated (flexor carpi radialis for MW and tibialis anterior for PT). In random trials, we also applied prepulse stimuli, either a low-intensity auditory stimulus or low-intensity electrical stimuli, 100 ms before the SSS-eliciting stimulus. The pattern of SSS was different for upper and lower limb stimuli. While stimuli applied to MW induced a prominent reaction of the OOC, at a mean latency of 61.1 ms (SD = 16.3 ms), followed by the SCM at a mean latency of 83.3 ms (SD = 28.6 ms), those applied to the PT caused a small or absent response in the OOC and a consistent response of the SCM at a mean latency of 89.7 ms (SD = 30.1 ms). Prepulse stimuli effectively inhibited the responses of facial and neck muscles but only partially those of the wrist flexors to MW or the tibialis anterior to PT. Our results indicate that, although there are common neck and facial muscle reactions to somatosensory stimuli applied to upper and lower limbs, the pattern of the SSS differs according to the source of the input. Prepulse inhibition is more effective on the responses of neck and facial muscles than on the responses of limb muscles to somatosensory stimuli. These results could help in distinguishing between withdrawal and SSS reactions.

Induction of cortical plastic changes in wrist muscles by paired associative stimulation in the recovery phase of stroke patients.

BACKGROUND: Paired associative stimulation (PAS) combining peripheral nerve and transcranial magnetic stimulation (TMS) have been proposed to induce long-term changes in excitability of the cerebral cortex and potentially optimize motor recovery in stroke patients. OBJECTIVE: This pilot study examined whether short-lasting changes in cortical excitability could be induced by a single session of PAS within the first months after stroke. METHODS: Six hemiparetic patients with a subcortical stroke were included. The single session PAS protocol was applied at 1, 5, and 12 months after stroke. During the follow-up, the clinical recovery of wrist function was assessed in parallel to the PAS study by the Fugl-Meyer motor scale and dynamometry of wrist extension. RESULTS: The PAS protocol induced a significant extensor carpi radialis motor evoked potential facilitation (mean +78.5%) on the paretic side 5 months after stroke. The facilitation was still present 12 months after stroke but on average smaller (+30 %). CONCLUSIONS: These electrophysiological findings suggest that patients with subcortical infarcts may respond to PAS in an earlier than later period after stroke. If the clinical efficacy of interventions such as PAS is confirmed, it could be proposed early as add-on therapy to optimize training-induced plasticity processes.

Quantitative application of transverse friction massage and its neurological effects on flexor carpi radialis.

The purpose of the study was to determine the effects of transverse friction massage (TFM) on flexor carpi radialis (FCR) motoneuron (MN) pool excitability. Twenty-eight healthy subjects were randomly assigned into massage and control groups. Pre- vs post-TFM H-reflex data were collected. Controls received a rest period instead of massage. Massage dose was standardized by a novel electronic method which recorded the massage rate, momentary pressure and total cumulative pressure (energy). Two-way ANOVA of H/M ratios derived from maximal amplitudes of Hoffman reflexes (Hmax) and motor responses (Mmax) was used to analyze neurological effects and group differences. Analysis of pressure/time curve data showed: mean massage rate was 0.501+/-0.005 Hz; mean duration of massage sessions was 184.6+/-26.4s; mean peak pressure was 4.990+/-1.006 psi. Hmax/Mmax ratios declined from 14.3% to 10.3% for massage (P<0.01) but showed no change for controls (P>0.05). In conclusion a novel quantitative approach to the study of massage has been demonstrated while testing the effects of TFM on FCR MN pool excitability. TFM appears to reduce MN pool excitability. The novel method of quantifying massage permits more rigorous testing of client-centered massage in future research.