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Biomedical subjects

K Malmgren

Publications and source records attributed to K Malmgren.

At least 37 records · Page 2Linked to original sources
PubMed1997

[Surgical treatment is efficient in epilepsy].

Epilepsy surgery has a very long tradition, and recent advances in diagnostic and surgical procedures have enabled a number of patients with drug-resistant epilepsy to be treated successfully. In addition to the conventional clinical work-up, candidates for epilepsy surgery undergo evaluation by a multidisciplinary team using a battery of neuroimaging and neurophysiological procedures. Such teams have been established at all six university hospitals in Sweden.

Epilepsy↗
PubMed1997

[Differential diagnosis in epilepsy. Anamnesis is still the most important guide].

Epilepsy is defined by the WHO as "a chronic brain disorder of various aetiologies characterised by recurrent seizures due to excessive discharge of cerebral neurones." There are many other episodic conditions including systemic, neurological and psychiatric disorders, which may be confused with epileptic seizures but are not the result of epileptic neuronal discharge. The principal differential diagnoses in cases of episodic seizures in adults and children are outlined in this review, and the importance of adequate history taking is stressed. Correct interpretation of the history is dependent upon the physician's recognition of the clinical features typical of epileptic seizures. Both the importance and the limitations of electroencephalography (EEG) are discussed. The contribution of EEG in cases where a diagnosis of therapy-resistant epilepsy has been questioned is exemplified in case studies of 42 patients, of whom 43 per cent were found to have psychiatric disease only, 26 per cent to have epilepsy only, 12 per cent to have both epileptic seizures and episodic symptoms of psychiatric origin, and the remaining 19 per cent to have episodic disorders of non-epileptic and non-psychiatric origin. The importance of adequate history taking before making a diagnosis of epilepsy is emphasised, as is the conclusion that an incorrect diagnosis of epilepsy often causes more harm than postponing the diagnosis until it becomes more clear.

Adult↗
PubMed1997

Prevalence of diabetic retinopathy in children and adolescents with IDDM. A population-based multicentre study.

Vision-threatening diabetic retinopathy can be prevented if it is diagnosed before becoming too advanced. Since diabetic retinopathy has been reported to occur only rarely before the end of pubertal development, children and adolescents are seldom included in screening programmes. We invited 780 children and adolescents with insulin-dependent diabetes mellitus diagnosed before the age of 15.0 years (disease duration of < 12 years) and who were older than 9.0 years at the time of examination from eight regions of Sweden. Retinal examination was performed with stereoscopic fundus photograph. The photograph were rated according to a modified Airlie House classification. The dropouts (223/780, 28.6%) were significantly older and with a longer duration of diabetes than the examined children (p < 0.001 and 0.001, respectively). Photographs from 557 patients aged (median [interquartile range]:14.6 [12.4-17.0]) years and with a diabetes duration of 8.0 (5.5-9.9) years were evaluated. Retinopathy was demonstrated in 81 patients (14.5%):66 with background retinopathy, 2 with microaneurysms and hard exudates, 12 with preproliferative retinopathy, 1 with proliferative retinopathy. Preproliferative retinopathy was diagnosed in a 12.8-year-old girl in pubertal stage 3 and an 11.8-year-old boy in pubertal stage 2, and proliferative retinopathy was found in a 21.5-year-old girl. Retinopathy was demonstrated in 6% and 18% of patients in pubertal stages 1 and 5, respectively. The overall prevalence of retinopathy in this population may even be higher since the dropouts were older and had a longer duration of diabetes. Since background and preproliferative retinopathy were found in children before puberty, we recommend including children and adolescents in screening programmes for diabetic retinopathy from the age of 10 years.

Adolescent↗
PubMed1997

Health-related quality of life after epilepsy surgery: a Swedish multicenter study.

PURPOSE: To investigate health-related quality of life (HRQOL) in relation to seizure outcome as part of a multicenter follow-up of epilepsy surgery in Sweden. METHODS: A battery including the SF-36 Health Survey and the Hospital Anxiety and Depression scale (HAD) was distributed to all patients older than 16 years. Mean follow-up time was 4 years (range, 2-13 years) and response rate, 91% (103 of 113 patients). HRQOL data were related to seizure frequency and severity (Chalfont Seizure Severity Scale). RESULTS: Seventy-six percent considered their global health to be better than it was before surgery. Degree of improvement in seizure control correlated with improved satisfaction with health (Spearman's r = 0.44). Higher SF-36 scores (higher HRQOL ratings) correlated with percentage reduction of seizure frequency for all scales and was strongest for perception of general health (Spearman's r = 0.46). When the patients were divided into four categories [A, completely seizure free (n = 29); B, seizure free with aura (n = 18); C, > or =75% reduction in seizure frequency (n = 24); and D, <75% reduction in seizure frequency (n = 32)], a strong positive association was found between higher SF-36 scores (with the exception of physical functioning) and better seizure control. Health-related limitations in role performance differentiated best between the outcome categories. For patients with > or =75% reduction in seizure frequency, low seizure severity correlated with higher HRQOL ratings for scales measuring social function, vitality, and mental health. Depression levels (HAD scale scores) were on average low. Anxiety (HAD) increased significantly from A to D. CONCLUSIONS: HRQOL seems to be scored as a continuum in relation to seizure frequency. Seizure severity measures give complementary information.

Adaptation, Psychological↗
PubMed1997

Surgical treatment for epilepsy: a retrospective Swedish multicenter study.

The characteristics of patients suffering from drug resistant epilepsy, including the results of the preoperative evaluation and epilepsy surgery were retrospectively analyzed in a Swedish multicenter 10-year cohort of children and adults. Altogether 152 patients (65 children and 87 adults) treated during the period 1980-1990 in three epilepsy centers were included and followed-up 2 years after surgery. Median age at onset of seizures was 4 years for the children and 12 years for the adults. A localization related epilepsy was present in 85% of the children and in 95% of the adults. The mean number of seizure types in the children was 1.7 (range 1-4) and in the adults 1.8 (range 1-4). The median monthly seizure frequency was 52 and 15 for children and adults respectively. Resective surgery was performed in 143 cases (94 temporal, 31 extratemporal, 9 multilobar and 9 major resection procedures) and palliative procedures in 16 cases (13 callosotomies and 3 stereotactic amygdalotomies). Postoperative neurological deficits were detected in 9% of the patients after temporal lobe resections and in 15% of the patients after extratemporal and multilobar resection procedures. Two years after resective surgery 53% of the children and 49% of the adults were seizure free. Another 25% of the patients had a more than 50% reduction of seizure frequency. In the postoperative non seizure free group of patients there was a negative correlation between decrease in weighted seizure severity and decrease in seizure frequency. This finding stresses the need for including other parameters than seizure frequency when evaluating the outcome of epilepsy surgery.

Adolescent↗
PubMed1996

Cortical reorganisation of sensory, motor and language functions due to early cortical damage.

During evaluation of a 22-year-old man for epilepsy surgery it was demonstrated that reorganisation of sensory, motor and language functions had occurred. Restricted perinatal lesions in the left frontal opercular region and in the hand primary sensory area had resulted in severe partial epilepsy and minor neuropsychological deficits, but no neurological deficits. The dominance for language and handedness was shifted to the right hemisphere but some language representation was still found in the left hemisphere. Threshold electrical stimulation via subdurally placed cortical electrodes revealed reorganisation of the hand sensory area in the left hemisphere. Hand sensory responses were electrically evoked close to the opercular region where also face sensory responses were recorded. Some of the sensory responses were located in the frontal lobe in the premotor cortex. The locations of the sensory representation areas differed from those expected neuroanatomically. The cortical motor responses were located around the presumed location of the precentral gyrus. These findings are considered to represent a functional intra- and interhemispherical reorganisation of cortical areas as a result of early cortical lesions, anatomically close to the somatosensory and language areas. A possible mechanism discussed is reorganisation of the thalamocortical projections.

Adult↗
PubMed1996

Cost analysis of epilepsy surgery and of vigabatrin treatment in patients with refractory partial epilepsy.

In this study the direct actual costs associated with epilepsy-related health care, treatment with the novel antiepileptic drug vigabatrin (gamma-vinyl GABA, GVG), epilepsy surgery evaluation (ESE) and epilepsy surgery were analysed in 52 patients with intractable partial epilepsy who were on a waiting-list for ESE while trying GVG. Sixty percent of the 52 patients obtained a reduction in seizure frequency of 50% or more with GVG. Of the twenty-one operated patients 57% became seizure free, 10% had more than 75%, 5% had 50-75% and 29% had less than 50% reduction of seizure frequency. Of the 17 patients who did not go through ESE (the "GVG responders"), the corresponding outcome was 6%, 59%, 29% and 6%. For the 14 patients who were neither operated nor GVG responders, the outcome was 0%, 0%, 36% and 64%. The mean yearly costs (expressed in 1991 prices) of epilepsy-related health care including antiepileptic drug treatment was US $1,594 the year before starting GVG therapy, and US $2959 the first year of GVG treatment including a mean yearly cost of GVG of US $1,572. The mean total cost for ESE and surgery was US $46,778 (N = 21), while the mean cost of ESE in patients evaluated but not accepted for surgery (N = 14) was US $24,054. Considering the costs for ESE and surgery in the whole patient series, the mean total cost of rendering one patient seizure free with surgery was US $110,000. Surgery is the most effective treatment option in selected cases of severe partial epilepsy. If its costs are distributed over the patient's expected lifetime, the yearly cost is comparable to the present yearly cost of medication with GVG. However, since many patients achieve satisfactory seizure control with GVG, and considering the risks of surgery, we consider it a rational policy to let patients try this drug (or another of the new generation of antiepileptic drugs) before entering ESE.

Adult↗
PubMed1994

Dendritic morphology in epileptogenic cortex from TRPE patients, revealed by intracellular Lucifer Yellow microinjection and confocal laser scanning microscopy.

Biopsy material was obtained from cortical epileptogenic zones (eight temporal, one occipital, one parietal and one frontal) of eleven patients aged 1.5-47 years with therapy-resistant partial epilepsy (TRPE) undergoing epilepsy surgery. Control autopsy material (two temporal, two occipital, one parietal and one frontal) was removed from six neurologically healthy cases within 6-10 hours postmortem delay. In each specimen, 100-300 pyramidal and non-pyramidal neurons were visualized by intracellular Lucifer Yellow microinjection. Single neurons were imaged using CLSM generated serial optical sections; 2-D reconstruction of each neuron was made using z-projection of serial optical images, and 3-D reconstructions and rotations were computerized. Neuronal maps from TRPE biopsies, compared to control autopsies, show markedly increased numbers of dendritic abnormalities of single pyramidal and non-pyramidal neurons in layers I, II-III, V-VII, and in the subcortical white matter. The abnormalities include: (1) increased number of non-pyramidal cells in layer I; (2) many pyramidal cells with two or three dendrites originating apically, rather than one single apical dendrite, in layers II-III; (3) atypical orientation of oblique apical and basal dendrites in pyramidal neurons of layers II-VII; (4) increased number of atypical 'dinosaur-like' and fusiform cells in layers V-VII; (5) numerous neurons in the white matter. These abnormalities may be etiological in cases with early onset, and predisposing in cases with late onset.

Adolescent↗
PubMed1992

A compound score for estimating the influence of inattention and somnolence during the intracarotid amobarbital test.

Alterations in the level of consciousness may render the interpretation of the memory test results from the intracarotid amobarbital procedure difficult. The present study was designed to investigate the impact of inattention and somnolence on memory performance during the Amytal test. Nineteen consecutive patients undergoing the test were investigated. The memory test was constructed to comprise two consecutive parts with identical design, so as to make possible comparisons over time in the same patients. Reaction level and somnolence were continuously assessed during the procedure and a stimulus-task response test to evaluate the degree of attention was used. On the basis of these parameters a compound 'inattention score' was constructed. The results indicate that inattention and somnolence negatively influence memory performance and should be taken into account when evaluating the Amytal memory test results. In cases with poor memory results high inattention scores may speak in favour of preoperative hemisphere memory testing or a repeat injection with reduced Amytal dosage before deciding upon the extent of a planned resection. On the other hand, low inattention scores together with amnesia for the testing procedure may indicate that the memory test results can be relied on.

Adult↗
PubMed1988

Evidence for non-monosynaptic Ia excitation of human wrist flexor motoneurones, possibly via propriospinal neurones.

1. The possibility that activation of low-threshold afferents in the median and ulnar nerves in man evokes an interneuronally mediated excitation of wrist flexor motoneurones was investigated. Two independent techniques were used: (i) the indirect technique of spatial and temporal facilitation of the flexor carpi radialis H reflex; (ii) the post-stimulus time histogram (PSTH) method for measurement of the firing probability of voluntarily activated motor units following different stimuli. 2. Conditioning volleys were evoked by weak electrical stimuli (to the median nerve, the ulnar nerve, the skin and cutaneous nerve branches) and by a tap to the tendon of the flexor carpi radialis muscle. 3. In the H reflex experiments the comparison was drawn between the effects of two conditioning stimuli applied separately or together. In some experimental conditions the facilitation of the reflex evoked when combining two conditioning stimuli was larger than the algebraic sum of the effects from separate stimuli. The central latency of this additional facilitation, which is denoted 'extra facilitation', was 3 ms. It is argued that the extra facilitation reflects summation at a premotoneuronal level. 4. PSTHs of voluntarily activated flexor carpi radialis and flexor carpi ulnaris motor units were computed following stimulation of the median or the ulnar nerve. In 60% of the recordings the afferent volley evoked a peak of increased firing probability with a latency which was 3-6 ms longer than the monosynaptic Ia latency. 5. Both the extra facilitation of the reflex and the late peak in the PSTH were evoked from very low-threshold afferents. A contribution from Ia afferents was demonstrated in reflex experiments. Group I afferents alone are responsible for the onset of the non-monosynaptic excitation but it is probable that cutaneous afferents give a later contribution. 6. On the basis of the characteristics of the non-monosynaptic excitation studied with the two methods (same very low-threshold, comparable central latencies), it is argued that both the extra facilitation of the H reflex on combined stimulation and the late peak in the PSTHs from individual motor units are mediated through the same pre-motoneuronal pathway. 7. The possibility that the non-monosynaptic excitation may be mediated through propriospinal neurones is discussed.

Adult↗
PubMed1988

Inhibition of neurones transmitting non-monosynaptic Ia excitation to human wrist flexor motoneurones.

1. The possibility was investigated that the transmission of the interneuronally mediated Ia excitation to wrist flexor motoneurones described in the companion paper is inhibited by stimulation of afferent fibres. Two techniques were used: (i) the post-stimulus time histogram (PSTH) method for studying changes in firing probability of individual voluntarily activated wrist flexor motor units following various peripheral stimulations; and (ii) the indirect technique of spatial facilitation of the H reflex. 2. In those individual units where stimulation of the median and/or the ulnar nerve evoked a non-monosynaptic excitation, this excitation was reduced when the afferent input was increased. This reduction of the non-monosynaptic Ia excitation was found in 80% of the motor unit recordings, whether the afferent input was increased by increasing the stimulus intensity to one nerve or by using combined stimulation of two nerves. 3. Both group I muscle and low-threshold cutaneous afferents were shown to be able to reduce the non-monosynaptic Ia excitation. 4. The onset of the depression of the excitation was always found within the same 1 ms bin as that of the excitation. 5. Whatever the amount of afferent input (stimulus intensity increased up to motor threshold, spatial and temporal summation, summation of inhibitory effects from different origins), the depression could at the very most suppress the non-monosynaptic Ia excitation: i.e. a trough in the PSTH, reflecting an inhibition at the motoneuronal level, never appeared. In those units in which there was not non-monosynaptic excitation, peripheral stimulation did not evoke any inhibition appearing as a trough in the PSTH either. Hence, inhibition only appeared when there was a non-monosynaptic excitation, and then as a depression of it. 6. On the basis of these findings it is argued that the inhibition is not exerted directly onto motoneurones but acts at a pre-motoneuronal level on the interneurones mediating the non-monosynaptic Ia excitation to motoneurones. 7. Similarly, the homonymous non-monosynaptic Ia facilitation of the flexor carpi radialis H reflex was shown to be reduced by a preceding stimulation applied to the ulnar nerve. It is argued that this result is also compatible with an inhibition of transmission in interneuronal excitatory pathways to motoneurones. 8. It is suggested that the non-monosynaptic excitation of wrist flexor motoneurones in man and the inhibition of this excitation, both evoked by stimulation of low-threshold afferents, could be mediated through a system of cervical propriospinal neurones. Some aspects of the possible role of this system during movement are discussed.

Adult↗
PubMed1988

On premotoneuronal integration in cat and man.

The first part of this thesis is concerned with reflex pathways from Ib afferents from Golgi tendon organs. Convergence at an interneuronal level was analyzed with intracellular recordings from lumbar motoneurones in acute spinal cats, and in human experiments using the H-reflex of flexor carpi radialis (FCR) as test. In both cases facilitation of Ib transmission by electrical stimulation of low threshold cutaneous afferents was obtained. On the basis of the results obtained in animal experiments, it is hypothesized that the cutaneous feed-back could supply a gain control in Ib pathways. Activation of a skin field in the course of an exploratory movement could then lead to a purposeful decrease of muscular force. The finding that cutaneous facilitation of Ib transmission in the human forearm could only be obtained from restricted receptive fields is taken to support this hypothesis. Other afferent systems converging onto the Ib inhibitory interneurones are discussed with emphasis on the Ia muscle spindle afferents. It is proposed that the latter provide dynamic sensitivity to the Ib inhibition and play a special role in the Ib control of muscle force which is exerted at the motoneuronal level. The second part is concerned with an interneuronal pathway from Ia afferents to motoneurones of forearm muscles, disclosed by a late (3 ms central latency) facilitation of the FCR H-reflex by conditioning stimulation of the median and ulnar nerves and by weak tendon taps. For the analysis of this interneuronal pathway the post stimulus time histogram (PSTH) method was utilized, activating individual wrist flexor motor units. Electrical stimulation of low threshold afferents in the median and ulnar nerves evoked an excitation with a latency at least 3 ms longer (mean 4.2 ms, range 3-6 ms) than the monosynaptic latency. Increasing the afferent input to voluntarily activated wrist flexor motor units resulted in a decrease of the non-monosynaptic excitation. This depression of the excitation could not be explained only by occlusion, but must involve an inhibitory mechanism. Findings are reported suggesting that this inhibition is not exerted directly onto the motoneurones, but acts on the interneurones mediating the excitation. Several characteristics of the non-monosynaptic excitation and its depression bear resemblance to those of a cervical propriospinal neuronal system in the cat, used as a model for the discussion.(ABSTRACT TRUNCATED AT 400 WORDS)

Afferent Pathways↗
PubMed1987

Reflex pathways from group II muscle afferents. 1. Distribution and linkage of reflex actions to alpha-motoneurones.

The interneuronally mediated reflex actions evoked by electrical stimulation of group II muscle afferents in low spinal cats have been reinvestigated with intracellular recording with motoneurones to knee flexors and ankle extensors. The results of Eccles and Lundberg (1959) have been confirmed and extended. There was wide convergence from flexors and extensors of group II excitation to flexor and group II inhibition to extensor motoneurones. Some quantitative differences in the effect from the different nerves are described. Latency measurements suggest that the minimal linkage is disynaptic in the excitatory interneuronal pathways and trisynaptic in the inhibitory pathways. Disynaptic group II EPSPs were found in 14% of the ankle extensor motoneurones but were much more common in unanaesthetized high spinal cats (Wilson and Kato 1965). From these results and corresponding ones on flexors (Holmqvist and Lundberg 1961) it is postulated that secondary afferents in addition to the weak monosynaptic connexions (Kirkwood and Sears 1975) have disynaptic excitatory pathways and trisynaptic inhibitory pathways to both flexor and extensor motoneurones. It is proposed that the group II actions of the flexor reflex pattern characterizing the anaesthetized low spinal cat are due to suppression of the inhibitory pathway to flexor motoneurones and the excitatory pathway to extensor motoneurones. In some ankle extensor motoneurones the disynaptic group II EPSPs occurred in combination with IPSPs from the FRA (including group II and III muscle afferents). The possibility is considered that these group II EPSPs are mediated by an interneuronal group II pathway with little or no input from group III muscle afferents but probably from extramuscular receptors. In other ankle extensor motoneurones group II EPSPs were combined with EPSPs from group III muscle afferents, cutaneous afferents and joint afferents. It is postulated that these group II EPSPs are mediated by an interneuronal pathway from the FRA which also supply interneuronal pathways giving inhibition to extensor or/and flexor motoneurones and excitation to flexors as postulated by Eccles and Lundberg (1959) and Holmqvist and Lundberg (1961).

Animals↗
PubMed1987

Reflex pathways from group II muscle afferents. 2. Functional characteristics of reflex pathways to alpha-motoneurones.

The convergence of group II muscle afferents on interneurones in reflex pathways has been elucidated by investigating interaction in transmission to motoneurones. Recording was also made from interneurones activated from group II afferents. Maximal group II EPSPs evoked in motoneurones from different muscles (extensors or flexors and extensors) did not summate linearly but with a deficit of 35-40%. The corresponding deficit in summation with Ia EPSPs was 7%. It is suggested that the difference in deficit is caused largely by occlusion due to shared interneuronal discharge zones and that it gives an approximate minimal measure of the convergence of group II afferents from different muscles on the interneurones. Tests with weak group II volleys from different muscles gave no or little evidence for spatial facilitation in the disynaptic excitatory pathway to flexor motoneurones, and there was no or little temporal facilitation of transmission in this pathway. It is suggested that group II excitation of the interneurones in this pathway depends on few afferents giving large unitary EPSPs. Convergence of cutaneous afferents and joint afferents on the interneurones was evidenced by spatial facilitation from these afferents of group II transmission to motoneurones. Convergence on interneurones in the trisynaptic inhibitory pathway from group II afferents to extensor motoneurones was also investigated with the spatial facilitation technique. There was convergence on common interneurones of group II afferents from different muscles (extensors or flexors and extensors) and from cutaneous afferents as well as joint afferents. Trisynaptic group II IPSPs, including those depending on spatial facilitation from different muscles were resistant to recurrent depression from motor axon collaterals and are therefore not mediated by the reciprocal Ia inhibitory pathway. Interneurones with monosynaptic group II EPSPs were recorded from in the dorsal horn and intermediate region. Graded stimulation revealed large unitary EPSPs from few group II afferents. The EPSP evoked by a single group II afferent may produce firing (extracellular recording). Convergence of monosynaptic group II EPSPs from different muscles was rather limited but could be from flexors and extensors. Extensive multisensory convergence onto some of these interneurones was indicated by di- or polysynaptic EPSPs from group II and III muscle afferents, from joint afferents and from cutaneous afferents.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1987

Reflex pathways from group II muscle afferents. 3. Secondary spindle afferents and the FRA: a new hypothesis.

A hypothesis is forwarded regarding the role of secondary spindle afferents and the FRA (flexor reflex afferents) in motor control. The hypothesis is based on evidence (cf. Lundberg et al. 1987a, b) summarized in 9 introductory paragraphs. Group II excitation. It is postulated that subsets of excitatory group II interneurones (transmitting disynaptic group II excitation to motoneurones) may be used by the brain to mediate motor commands. It is assumed that the brain selects subsets of interneurones with convergence of secondary afferents from muscles whose activity is required for the movement. During movements depending on coactivation of static gamma-motoneurones impulses in secondary afferents may servo-control transmission to alpha-motoneurones at an interneuronal level. The large group II unitary EPSPs in interneurones are taken to indicate that, given an adequate interneuronal excitability, impulses in single secondary afferents may fire the interneurone and produce EPSPs in motoneurones; interneuronal transmission would then be equivalent to that in a monosynaptic pathway but with impulses from different muscles combining into one line. It is postulated that impulses in the FRA are evoked by the active movements and that the role of the multisensory convergence from the FRA onto the group II interneurones is to provide the high background excitability which allows the secondary spindle afferents to operate as outlined above. The working hypothesis is put forward that a movement governed by the excitatory group II interneurones is initiated by descending activation of these interneurones, but is maintained in a later phase by the combined effect of FRA activity evoked by the movement and by spindle secondaries activated by descending activation of static gamma-motoneurones. As in the original "follow up length servo" hypothesis (Rossi 1927; Merton 1953), we assume that a movement at least in a certain phase can be governed from the brain solely or mainly via static gamma-motoneurones. However, our hypothesis implies that the excitatory group II reflex connexions have a strength which does not allow transmission to motoneurones at rest and that the increase in the gain of transmission during an active movement is supplied by the movement itself. Group II inhibition. It is suggested that the inhibitory reflex pathways like the excitatory ones have subsets of interneurones with limited group II convergence. When higher centres utilize a subset of excitatory group II interneurones to evoke a given movement, there may mobilize inhibitory subsets to inhibit muscles not required in the movement.(ABSTRACT TRUNCATED AT 400 WORDS)

Afferent Pathways↗