Friday, May 9, 2014

Holy Water or Moonshine

It's been an eventful time around here.

I was going to regale you with a comedic chronicle of my trip to the ER/ED on Sunday, but am still feeling the excess pain which sent me there, so the usual bad jokes and finely honed sardonicism have not shown up to play Muse.

Fred has returned to the Board of Divinity at his congregation of primarily militant lesbian existentialist feminists.  More importantly.  No, not "importantly." (See?  This is the problem of working, not just without a net, but without prancing muses.)  More like... "earth-shatteringly."  What action do these top heavy adverbs modify?  That would be Fred's decision to undertake ministerial training.

That's right.  At some point in the next few years, I'll be living in sin with Pastor Fred.  Minister Fred. Fred, His Holiness.  I haven't hit on the right honorific.

His motivations shift between murky desires to set Those Women straight, so to speak, and a saintly urge to promote a humanist outlook, informed by existential psychology, with overtones of Christianity and, unbeknownst to Fred, himself, Buddhism.  

My role is dicey.  I am dedicated to supporting Fred in any endeavor he chooses to undertake, as well as trying to lead him down various paths of unexpected passions and occasionally pushing him into dark, dank alleys of... 

Excuse me!  I must interrupt to share Miss Phryne Fisher's best line of the evening:  "I wonder where you have to go in this town to find a Latvian anarchist."  

As do I, Phyne, as do I.

Back to our eventful week.  And yes, I have the television on, as, lacking whispering muses, I need the noise.

This is the time of year when the frequency of correspondence between me and my Brother-Unit Grader Boob increases dramatically. (He's an English prof and dubbed himself "Grader Boob" several years back.  It is an odd moniker, but strangely fitting, as he sheds blood, sweat, and tears in the grading of his collegiate writers' scribblings.  I know, as only a sisterly prof can know, that he spends more time on his marginalia and end-of-paper commentaries than the students do in composing their texts.)

We're both tennis fans, and the pent up fervor of the Australian, Spanish, and French Opens bursts into outright fanaticism by Wimbledon and the U.S. Open.  

But, frankly, he's been kind of pissy these past few years, my Grader Boob.  The stress of being strung along in poverty by university administrators abusing their instructors -- keeping them just shy of full time employment, without benefits, but with a surplus of students -- seems to be taking its toll on his good nature.

Just between you and me, Grader Boob is such a... guy.  Throughout the years, he's suffered his share of physical ailments but tended to choose his buddy, the chiropractor, over the medical school on campus.  For the longest time, his greatest problem seemed to be some arthritic changes in his knees due to wearing cheap ass tenny-pumps when he passed every spare minute on outdoor racketball courts -- whose composition was primarily asphalt.  He was quite a talented champion.  Hmm.  He may also have invested in acupuncture, as well as having his spine adjusted, or whatever it is that chiropractors do.  The short version;  Grader Boob is, generally, averse to mainstream medical practitioners.

I don't blame him and admit to possibly influencing him in this matter.  He's often the first I notify of bad medical news, to the point, I think, that his eyes may have rolled back in his head a few times, from frustration.  Or boredom.  Or fear.

Once, the idiots in the ICU allowed me a telephone, so that I could call him to say "Thanks!" for having landed a helicopter on the hospital roof, rappelling down to the unit, entering my cubicle via an intricate channel of vents and weird tubing that let out through one of the ceiling panels over my bed, and extricating me from... wherever the hell I thought I was being held by white-coated fiends. Then, as the story went in my addled mind, he found me a nice B & B in which to recuperate before flying off with his Delta Force friends. I had MRSA pneumonia, had died and been resuscitated twice, was surrounded by staff outfitted in disposable, baggy, yellow gowns, with gloves and scary masks.  To which I responded with a whopping case of ICU Psychosis.  But, as I said, the nurses, who were delighted by my apparent return to sanity, brought me a phone so that I could make a long distance call to this dear Brother-Unit, who did not even know I was hospitalized -- a call which opened with me crowing:  "Grader Boob, I did not even know you knew how to pilot a helicopter!" 

He's a humble person, a loving sibling, and terrific friend.  His sense of humor is such that, no matter the circumstances, I am reduced to puddles of mirth within minutes of our obtuse exchanges.

He's also a wounded man with low self-esteem and an undiagnosed, untreated case of clinical depression.  Okay, well, *I* made the diagnosis, but no actual medico.  Some of his innate sadness comes from what happens to us all -- a lost true love, a troubled childhood, the pain of absence, the burdens of an intellect weighed down by a hypersensitive soul.  Which makes him being a total hoot such a wonder!

Whereas the rest of my family express our genetic trait of moral intransigence by waging war -- on injustice, on unarmed civilians, on anything easily sorted into black, into white, on each other -- Grader Boob turned on himself.  He's never tasted alcohol.  Never tried a cigarette, never tried a joint. He shuns those things that whiff of sin.  After moving every two years or so as a kid, when he landed in a sunny city by a lovely bay to attend college, he vowed to never move again -- and didn't.  Even when the teaching jobs dried up and the hurricanes raged, he stayed put.

As I unleashed my tightly bound memory late last night, I recalled the many instances in the last few years when Grader Boob mentioned being exhausted, yet plagued with insomnia, catching a cold that he couldn't seem to shake, and becoming a bit fed up with fighting plagiarism and indifference to subject-verb agreement. I joked in response, once sending a box full of easy soups, crackers, decongestants, Vapor Rub, and a Harry Potter muffler.  Okay, and a coloring book with a box of 64 Crayolas.

He never told me about going to the ER/ED last October when his shoulder caused him such enormous pain he couldn't stand it any longer.  At least, I pray he did not tell me, because I don't remember hearing it.  As I heard the story this week, they were somewhat dismissive, as health care professionals in emergency rooms can be when faced with what they don't consider a true emergency and in an uninsured patient, no less.

So this overworked and uninsured professor decided to wait until he could afford health insurance via the Affordable Care Act's Market Place.  As he waited, and he waited until March, the shoulder became essentially frozen, and he said it was painful just trying to dress before heading off to demonstrate demonstrative adjectives and the more egregious logical fallacies.

By the time he saw an orthopedic surgeon, there was a visible lump, very painful to the touch.  By the time he had the MRI on Wednesday, the inconsequential "calcium deposits" posited by the ER doctor last October, had become a fairly large tumor.  Oh, and the surgeon noted that there was a problem with his rotator cuff, before sending him to the Sarcoma Clinic of the nearby Cancer Center.

Everyone claims they "had a feeling." I had a feeling, but it was fed by the knowledge that only something serious would drive my recalcitrant brother into the realm of conventional medicine. 

But what's weird is that I had an appointment already scheduled with my fabulous Dr. Shoulder Man for today.  Grader Boob had been tossed into the chasm of confusion that comes with health insurance -- the Cancer Center's Sarcoma Clinic was not in his "network," and he somehow found himself with an appointment for JUNE.  He was, of course, in shock.  He quickly pulled himself together and began working the phones like an insured pro, comforting himself (and me) by remembering that he had his first meeting with his new Primary Care Doc on Friday... and surely he would be able to find him an orthopedic oncologist.  Before JUNE.

Dr. Shoulder Man's PA, a wonderful man named Bob, was immediately helpful, as I assaulted him with Grader Boob's situation before his hand left the door knob of the exam room.  Bob is a good'un, as are all of Dr. Shoulder Man's team. He managed to scoot my ass over to get x-rays before bringing in Dr. Shoulder Man.  I was able to wait until he was injecting me with Magic Juice before my second assault.

My God, there are kind people in this world.

"Do you know anyone in Grader Boob's town -- who is the very best, do you know?"
And what did my wondering ears get to hear but:  "One of the world's best orthopedic surgeons practices there, Dr. Wonder Worker..." He went on to explain the things I was afraid to ask -- how they'd go about the biopsy, how very little can be presumed without those results, as there are some dozen sarcomas common to adults, and his voice was crisp, clear, authoritative, but compassionate, too.  He was quite plain about the likelihood of this being a cancer, and the unfortunate consequences of how long Grader Boob had to wait before getting the MRI.

Smoothly switching to talking about my one prosthetic shoulder and my other shoulder region that actually has no shoulder, we had an exchange in which I proposed ignoring and putting off some decisions.  Slick as satin, Shoulder Man said, "So, I see that denial is a family trait," and grinned before sashaying out the door.

Grader Boob is completely capable of handling all this, of sorting through information, making decisions, and conquering this illness with panache.  I felt like a nosy, loud, interfering dolt as I shot off an email when we got home, complete with links to Dr. Wonder Worker's background, and a satellite map of his location, with his office, gym, and yacht phone numbers.  My hands were cold because I had no idea if Dr. Wonder Worker would prove to be in Grader Boob's insurance network, and my lips were cold because I wanted to touch him, hold his hand, and stroke his longish curly hair.

Wonder of wonders, I got an answer a bit later -- the good doctor, this *best* doctor, was, indeed, available to him.  Wisely, my brother said he'd take the information to his appointment tomorrow, and then would follow the winding trail of bread crumbs.

My two brothers are a wonder to me, a blessing undeserved and continually surprising.  

And they shake me, shake me to my core.  I love them without really knowing them, and do so cognizant that our very existences are a wonder, our relationships, so simple and so complex, practically accidental.

I would do anything, anything, anything to help Grader Boob, to help TW -- if only we three could defeat our inherited intransigence -- and denial, our "family trait."  But we have our wily ways, our shifty humor, words, and that shared ineffable something common to deaf-mutes.

Good night, Grader Boob.  Good night, TW.  I am holding your hands.  If you should need any ministerial services, Fred has set up his work room with beakers and copper tubing, pipettes and kegs 'n such, determined to transform our murky, algae-ridden moat waters into Holy Water. 

Or moonshine.

Wynken, Blynken, and Nod by Mandy Moore

Tuesday, May 6, 2014

"Case report: Long-standing complex regional pain syndrome relieved by a cephalosporin antibiotic"

My last post today featured the type of research we all hope for -- quantitatively accessible, peer-reviewed, standardized.  But the world of CRPS research, by the nature of the disease, is most often driven by the lone "case study," and, often, by "coincidental" discoveries.  So long as we have such limited treatment, and no cure at all, there is little disincentive to ignore anything.

What makes this article of interest to me is my personal experience of improvement in CRPS pain during unrelated courses of certain antibiotics.  I was unaware of it until my Go-To-Guy doctor reacted to one of my statements by flipping through my chart and discovering that he had noted the same observation from me over time, several times.  The antibiotics were, as it happens, cephalosporins.  I don't place enough trust in my perceptions to tout that as any sort of proof, and present it simply as information.

Case report: Long-standing complex regional pain syndrome relieved by a cephalosporin antibiotic

  • Mark A. WareabeCorresponding author contact informationE-mail the corresponding author
  • Gary J. Bennettcde
  • AbstractWe describe a young woman who had had treatment-refractory complex regional pain syndrome (CRPS) for 6 years before receiving antibiotic treatment with cefadroxil (a cephalosporin derivative) for a minor infection. Cefadroxil reduced the patient’s pain and motor dysfunction (dystonia and impaired voluntary movement) within days; the pain and motor disorder returned when cefadroxil was discontinued; and both again abated when cefadroxil was re-instituted. The patient has now had symptom relief for more than 3 years on continuing cefadroxil therapy. We discuss this case in the context of previous reports of antibiotic treatment relieving neuropathic pain in experimental animals.

    "TMS motor cortical brain mapping in patients with complex regional pain syndrome type I"

    from the Journal of Neurophysiology:
    "Habenula functional resting-state connectivity in pediatric CRPS"

    This is exciting.  I wish more mapping of people with CRPS [including Type 2, for those of us who have both] were being done.  Perhaps it will be a growing sector in the research.

    Even though this dates from 2006 (Clinical Neurophysiology : Official Journal of the International Federation of Clinical Neurophysiology [2006, 117(1):169-176]), it's new to me.  Forgive me if it's old news to you!

    These scientists are located in Munich and limited their look to people with one hand/arm involvement. That's how this will have to progress for good science, I suppose, limiting the study, enhancing its specificity.

    [I will momentarily bring us all down by noting a meta review article published in the Journal of Pain late last year.  It, too, is obviously worth reading.  The underlying complaint is familiar -- and explicable -- and that is that the cohorts were too small, the risk of bias is too high.  My knee-jerk reaction is that it is nigh unto impossible to assemble a sufficient number of CRPS patients to satisfy the stringent requirements necessary to good, repeatable studies.]

    One fine day ("a perfect day for bananafish," at the rate this gimp is going), my cheapo-cheapo no-contract disposable flip phone will ring, anemically, and it will be the bestest CRPS researchers in the whole wide, wide, broad world, asking to map my afflicted brain.  I imagine they'll faint straightaway at the sight of its shifty hemispheres and perverse lack of neuroplasticity.

    Remind me, Dear Readers (especially you, Beloved TW) to rain down upon you the hilarious story of my first ever trip to the Emergency Room (or ED, if you're WhiteCoat) for PAIN, something I swore never to do.  Well, swearing is not eternally binding.  At least not according to Tête de Hergé statutes, all put on college-ruled paper by that recently deceased Law & Morals activist, Tante Louise, about ten years ago.  Before that, we were ruled by one of those Mosaic * type tablet thingies. Very heavy, burdensome to have copied, and therefore oft ignored -- but no longer!  It will soon be available online.  We expect a total reworking to surge from that publication of all Judeo-Christian Hammurabi sorts of statute code.

    According to the Bible, there were two sets [of stone tablets]. The first, inscribed by God, were smashed by Moses when he was enraged by the sight of the Children of Israel worshiping the Golden Calf; and the second, later cut by Moses and rewritten by God.

    I'll give you one of the funnier tidbits about the ER visit, just to tide you elle est belle la seine addicts over until I can fix you a fix:  The radiologist who tried to interpret the x-ray of my left shoulder (the punchline is that I do not HAVE a left shoulder) was valiant in his verbiage as he tried to describe what he saw, as he had never encountered a sentient being lacking a shoulder before... and the referring ER/ED doc forgot to warn him ahead of time.  It was an agonal effort, but hilarious.  

    Right!  So!  This is exciting!  
    TMS = Transcranial magnetic stimulation

    TMS motor cortical brain mapping in patients with complex regional pain syndrome type I

    Department of Neurology, University of Munich, Klinikum Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany


    OBJECTIVE: The motor cortical representation in patients with complex regional pain syndrome type I (CRPS I) was determined under the assumption that the motor cortex undergoes representational adaptations in the course of CRPS.

    METHODS: A total of 14 patients with CRPS I and a group of healthy subjects without any known neurological symptoms participated in the study. The motor cortical representation, i.e. the size of representation (cm2), motor-evoked potentials (MEP), the calculated volume (cm2 mV), and the center of gravity (CoG) were measured by transcranial magnetic stimulation. Recordings were made of the long extensor muscles of the forearm of the affected and unaffected hand.

    RESULTS: Analyses of the results revealed a significant asymmetry between the two hemispheres: the motor cortical representation corresponding to the unaffected hand was significantly larger. While the CoG data did not differ statistically between the two hemispheres, the CoG coordinates corresponding to the affected hand indicated a larger variability.

    CONCLUSIONS: The presence of pain and other CRPS symptoms may induce lasting changes in motor cortical plasticity, as it also does in the sensory cortex.

    SIGNIFICANCE: This could be of importance in rehabilitative strategies for the sensory motor system in CRPS I patients.
    As I cannot access the article in its entirety from the journal Clinical Neurophysiology due to a scarcity of funds, below please put to good use the references employed in the article -- always a source of gems for background study and getting a better foundation for understanding the work, and its orientation or biases. Giving it a cursory glance, I see well-known, trustworthy, and up-to-date (for its time) sourcing.  As in, no evidence of that Turd, Ochoa, for instance.  It's a Turd Free Zone.

    I don't know if I've mentioned it or not, but searchable data from was recently released by NIH listing grant fund recipients and it was appalling to see the amount of money The Turd & his Oregon associates have pilfered.

    Appalling, I said.
    Money that could have fed hungry people, helped sick people, protected the environment, and provided for finely-targeted extra-judicial executions by drone.  Oregonians, as a whole, are a marvelous group of non-turdish people, and so one would have to be exquisitely precise in the deployment of those drones...

    Right!  So!  This is exciting! Put on your slippers and your reading glasses, brew a cuppa, and get to work understanding how TMS motor cortex brain mapping is done and why it matters for CRPS research. Fun,fun, fun!


    1. Amunts K, Jancke L, Mohlberg H, Steinmetz H, Zilles KInterhemispheric asymmetry of the human motor cortex related to handedness and gender. Neuropsychologia2000;38(3):304–312
    2. Birklein FComplex regional pain syndrome. J Neurol2005;252(2):131–138
    3. Bruehl S, Harden RN, Galer BS, Saltz S, Bertram M, Backonja M, et alExternal validation of IASP diagnostic criteria for complex regional pain syndrome and proposed research diagnostic criteria. International Association for the Study of Pain. Pain.1999;81(1–2):147–154
    4. Butefisch CM, Davis BC, Wise SP, Sawaki L, Kopylev L, Classen J, et alMechanisms of use-dependent plasticity in the human motor cortex. Proc Natl Acad Sci USA2000;97(7):3661–3665
      • Butefisch CM, Davis BC, Sawaki L, Waldvogel D, Classen J, Kopylev L, et alModulation of use-dependent plasticity by d-amphetamine. Ann Neurol2002;51(1):59–68
      • Cahn SD, Herzog AG, Pascual-Leone APaired-pulse transcranial magnetic stimulation: effects of hemispheric laterality, gender, and handedness in normal controls. J Clin Neurophysiol2003;20(5):371–374
      • Cheong JY, Yoon TS, Lee SJEvaluations of inhibitory effect on the motor cortex by cutaneous pain via application of capsaicin. Electromyogr Clin Neurophysiol2003;43(4):203–210
      • Cicinelli P, Traversa R, Bassi A, Scivoletto G, Rossini PMInterhemispheric differences of hand muscle representation in human motor cortex. Muscle Nerve1997;20(5):535–542
      • Classen J, Liepert J, Wise SP, Hallett M, Cohen LGRapid plasticity of human cortical movement representation induced by practice. J Neurophysiol1998;79(2):1117–1123
      • Cohen LG, Ziemann U, Chen R, Classen J, Hallett M, Gerloff C, et alStudies of neuroplasticity with transcranial magnetic stimulation. J Clin Neurophysiol1998;15(4):305–324
      • Delvaux V, Alagona G, Gerard P, De P V, Pennisi G, de Noordhout AMPost-stroke reorganization of hand motor area: a 1-year prospective follow-up with focal transcranial magnetic stimulation. Clin Neurophysiol2003;114(7):1217–1225
      • Dettmers C, Adler T, Rzanny R, van Schayck R, Gaser C, Weiss T, et alIncreased excitability in the primary motor cortex and supplementary motor area in patients with phantom limb pain after upper limb amputation. Neurosci Lett.2001;307(2):109–112
      • Fadiga L, Craighero L, Dri G, Facchin P, Destro MF, Porro CACorticospinal excitability during painful self-stimulation in humans: a transcranial magnetic stimulation study. Neurosci Lett2004;361(1–3):250–253
      • Farina S, Valeriani M, Rosso T, Aglioti S, Tamburin S, Fiaschi A, et alTransient inhibition of the human motor cortex by capsaicin-induced pain. A study with transcranial magnetic stimulation. Neurosci Lett2001;314(1–2):97–101
      • Flor H, Elbert T, Knecht S, Wienbruch C, Pantev C, Birbaumer N, et alPhantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature1995;375(6531):482–484
      • Flor H, Braun C, Elbert T, Birbaumer NExtensive reorganization of primary somatosensory cortex in chronic back pain patients. Neurosci Lett1997;224(1):5–8
      • Hallett MPlasticity of the human motor cortex and recovery from stroke. Brain Res Brain Res Rev2001;36(2–3):169–174
        • Hamdy S, Rothwell JC, Fraser C, Power M, Gow D, Thompson DGPatterns of excitability in human esophageal sensorimotor cortex to painful and nonpainful visceral stimulation. Am J Physiol Gastrointest Liver Physiol2002;282(2):G332–G337
        • Janig W, Baron RComplex regional pain syndrome is a disease of the central nervous system. Clin Auton Res.2002;12(3):150–164
        • Janig W, Baron RComplex regional pain syndrome: mystery explained?. Lancet Neurol2003;2(11):687–697
        • Juottonen K, Gockel M, Silen T, Hurri H, Hari R, Forss NAltered central sensorimotor processing in patients with complex regional pain syndrome. Pain2002;98(3):315–323
        • Kaelin-Lang A, Luft AR, Sawaki L, Burstein AH, Sohn YH, Cohen LGModulation of human corticomotor excitability by somatosensory input. J Physiol2002;540(Pt 2):623–633
        • Krause P, Foerderreuther S, Straube ABilateral motor cortex disinhibition in complex regional pain syndrome (CRPS) type I of the hand. Neurology2004;62(9):1654–1655
          • Krause P, Foerderreuther S, Straube A. Effects of conditioning peripheral repetitive magnetic stimulation in patients with complex regional pain syndrome. Neurol Res 2005;27(4):412–417.
            • Le Pera D, Graven-Nielsen T, Valeriani M, Oliviero A, Di L V, Tonali PA, et alInhibition of motor system excitability at cortical and spinal level by tonic muscle pain. Clin Neurophysiol2001;112(9):1633–1641
            • Maihofner C, Handwerker HO, Neundorfer B, Birklein FPatterns of cortical reorganization in complex regional pain syndrome.Neurology2003;61(12):1707–1715
              • Migita K, Uozumi T, Arita K, Monden STranscranial magnetic coil stimulation of motor cortex in patients with central pain.Neurosurgery1995;36(5):1037–1039
              • Miranda PC, de Carvalho M, Conceicao I, Luis ML, Ducla-Soares EA new method for reproducible coil positioning in transcranial magnetic stimulation mapping. Electroencephalogr Clin Neurophysiol1997;105(2):116–123
              • Murase N, Duque J, Mazzocchio R, Cohen LGInfluence of interhemispheric interactions on motor function in chronic stroke. Ann Neurol2004;55(3):400–409
              • Oldfield RCThe assessment and analysis of handedness: the Edinburgh inventory. Neuropsychologia1971;9(1):97–113
              • Pascual-Leone A, Torres FPlasticity of the sensorimotor cortex representation of the reading finger in Braille readers.Brain1993;116(Pt 1):39–52
                • Pleger B, Tegenthoff M, Schwenkreis P, Janssen F, Ragert P, Dinse HR, et alMean sustained pain levels are linked to hemispherical side-to-side differences of primary somatosensory cortex in the complex regional pain syndrome I. Exp Brain Res2004;155(1):115–119
                • Pleger B, Janssen F, Schwenkreis P, Volker B, Maier C, Tegenthoff MRepetitive transcranial magnetic stimulation of the motor cortex attenuates pain perception in complex regional pain syndrome type I. Neurosci Lett2004;356(2):87–90
                • Pleger B, Tegenthoff M, Ragert P, Forster AF, Dinse HR, Schwenkreis P, et alSensorimotor returning in complex regional pain syndrome parallels pain reduction. Ann Neurol2005;57(3):425–429
                • Priori A, Oliviero A, Donati E, Callea L, Bertolasi L, Rothwell JCHuman handedness and asymmetry of the motor cortical silent period. Exp Brain Res1999;128(3):390–396
                • Romaniello A, Cruccu G, McMillan AS, Arendt-Nielsen L, Svensson PEffect of experimental pain from trigeminal muscle and skin on motor cortex excitability in humans. Brain Res2000;882(1–2):120–127
                • Rossi S, Rossini PMTMS in cognitive plasticity and the potential for rehabilitation. Trends Cogn Sci2004;8(6):273–279
                • Sanes JN, Donoghue JPPlasticity and primary motor cortex. Annu Rev Neurosci2000;23:393–415
                • Schwenkreis P, Janssen F, Rommel O, Pleger B, Volker B, Hosbach I, et alBilateral motor cortex disinhibition in complex regional pain syndrome (CRPS) type I of the hand. Neurology2003;61(4):515–519
                  • Schwenkreis P, Maier C, Tegenthoff MFluctuations of motor cortex excitability in pain syndromes. Suppl Clin Neurophysiol.2003;56:394–399
                  • Siebner HR, Rothwell JTranscranial magnetic stimulation: new insights into representational cortical plasticity. Exp Brain Res2003;148(1):1–16
                  • Soros P, Knecht S, Bantel C, Imai T, Wusten R, Pantev C, et alFunctional reorganization of the human primary somatosensory cortex after acute pain demonstrated by magnetoencephalography. Neurosci Lett2001;298(3):195–198
                  • Thickbroom GW, Byrnes ML, Mastaglia FLA model of the effect of MEP amplitude variation on the accuracy of TMS mapping.Clin Neurophysiol1999;110(5):941–943
                  • Ziemann U, Lonnecker S, Steinhoff BJ, Paulus WEffects of antiepileptic drugs on motor cortex excitability in humans: a transcranial magnetic stimulation study. Ann Neurol1996;40(3):367–378
                  • Ziemann U, Corwell B, Cohen LGModulation of plasticity in human motor cortex after forearm ischemic nerve block. J Neurosci1998;18(3):1115–1123