@article {4436,
	title = {The Evoked Potential Operant Conditioning System (EPOCS): A Research Tool and an Emerging Therapy for Chronic Neuromuscular Disorders.},
	journal = {J Vis Exp},
	year = {2022},
	month = {2022 08 25},
	abstract = {<p>The Evoked Potential Operant Conditioning System (EPOCS) is a software tool that implements protocols for operantly conditioning stimulus-triggered muscle responses in people with neuromuscular disorders, which in turn can improve sensorimotor function when applied appropriately. EPOCS monitors the state of specific target muscles-e.g., from surface electromyography (EMG) while standing, or from gait cycle measurements while walking on a treadmill-and automatically triggers calibrated stimulation when pre-defined conditions are met. It provides two forms of feedback that enable a person to learn to modulate the targeted pathway{\textquoteright}s excitability. First, it continuously monitors ongoing EMG activity in the target muscle, guiding the person to produce a consistent level of activity suitable for conditioning. Second, it provides immediate feedback of the response size following each stimulation and indicates whether it has reached the target value. To illustrate its use, this article describes a protocol through which a person can learn to decrease the size of the Hoffmann reflex-the electrically-elicited analog of the spinal stretch reflex-in the soleus muscle. Down-conditioning this pathway{\textquoteright}s excitability can improve walking in people with spastic gait due to incomplete spinal cord injury. The article demonstrates how to set up the equipment; how to place stimulating and recording electrodes; and how to use the free software to optimize electrode placement, measure the recruitment curve of direct motor and reflex responses, measure the response without operant conditioning, condition the reflex, and analyze the resulting data. It illustrates how the reflex changes over multiple sessions and how walking improves. It also discusses how the system can be applied to other kinds of evoked responses and to other kinds of stimulation, e.g., motor evoked potentials to transcranial magnetic stimulation; how it can address various clinical problems; and how it can support research studies of sensorimotor function in health and disease.</p>},
	keywords = {Chronic Disease, Conditioning, Operant, Electromyography, Evoked Potentials, H-Reflex, Humans, Neuromuscular Diseases, Spinal Cord Injuries},
	issn = {1940-087X},
	doi = {10.3791/63736},
	author = {Hill, N Jeremy and Gupta, Disha and Eftekhar, Amir and Brangaccio, Jodi A and Norton, James J S and McLeod, Michelle and Fake, Tim and Wolpaw, Jonathan R and Thompson, Aiko K}
}
@article {4366,
	title = {Breathable, large-area epidermal electronic systems for recording electromyographic activity during operant conditioning of H-reflex.},
	journal = {Biosens Bioelectron},
	volume = {165},
	year = {2020},
	month = {10/2020},
	pages = {112404},
	abstract = {<p>Operant conditioning of Hoffmann{\textquoteright}s reflex (H-reflex) is a non-invasive and targeted therapeutic intervention for patients with movement disorders following spinal cord injury. The reflex-conditioning protocol uses electromyography (EMG) to measure reflexes from specific muscles elicited using transcutaneous electrical stimulation. Despite recent advances in wearable electronics, existing EMG systems that measure muscle activity for operant conditioning of spinal reflexes still use rigid metal electrodes with conductive gels and aggressive adhesives, while requiring precise positioning to ensure reliability of data across experimental sessions. Here, we present the first large-area epidermal electronic system (L-EES) and demonstrate its use in every step of the reflex-conditioning protocol. The L-EES is a stretchable and breathable composite of nanomembrane electrodes (16 electrodes in a four by four array), elastomer, and fabric. The nanomembrane electrode array enables EMG recording from a large surface area on the skin and the breathable elastomer with fabric is biocompatible and comfortable for patients. We show that L-EES can record direct muscle responses (M-waves) and H-reflexes, both of which are comparable to those recorded using conventional EMG recording systems. In addition, L-EES may improve the reflex-conditioning protocol; it has potential to automatically optimize EMG electrode positioning, which may reduce setup time and error across experimental sessions.</p>},
	keywords = {Biosensing Techniques, Conditioning, Operant, Electronics, H-Reflex, Humans, Reproducibility of Results},
	issn = {1873-4235},
	doi = {10.1016/j.bios.2020.112404},
	author = {Kwon, Young-Tae and Norton, James J S and Cutrone, Andrew and Lim, Hyo-Ryoung and Kwon, Shinjae and Choi, Jeongmoon J and Kim, Hee Seok and Jang, Young C and Wolpaw, Jonathan R and Yeo, Woon-Hong}
}
@article {3390,
	title = {Locomotor impact of beneficial or nonbeneficial H-reflex conditioning after spinal cord injury.},
	journal = {J Neurophysiol},
	volume = {111},
	year = {2014},
	month = {03/2014},
	pages = {1249-58},
	abstract = {When new motor learning changes neurons and synapses in the spinal cord, it may affect previously learned behaviors that depend on the same spinal neurons and synapses. To explore these effects, we used operant conditioning to strengthen or weaken the right soleus H-reflex pathway in rats in which a right spinal cord contusion had impaired locomotion. When up-conditioning increased the H-reflex, locomotion improved. Steps became longer, and step-cycle asymmetry (i.e., limping) disappeared. In contrast, when down-conditioning decreased the H-reflex, locomotion did not worsen. Steps did not become shorter, and asymmetry did not increase. Electromyographic and kinematic analyses explained how H-reflex increase improved locomotion and why H-reflex decrease did not further impair it. Although the impact of up-conditioning or down-conditioning on the H-reflex pathway was still present during locomotion, only up-conditioning affected the soleus locomotor burst. Additionally, compensatory plasticity apparently prevented the weaker H-reflex pathway caused by down-conditioning from weakening the locomotor burst and further impairing locomotion. The results support the hypothesis that the state of the spinal cord is a "negotiated equilibrium" that serves all the behaviors that depend on it. When new learning changes the spinal cord, old behaviors undergo concurrent relearning that preserves or improves their key features. Thus, if an old behavior has been impaired by trauma or disease, spinal reflex conditioning, by changing a specific pathway and triggering a new negotiation, may enable recovery beyond that achieved simply by practicing the old behavior. Spinal reflex conditioning protocols might complement other neurorehabilitation methods and enhance recovery.},
	keywords = {Animals, Conditioning, Operant, Female, H-Reflex, Learning, Locomotion, Male, Rats, Rats, Sprague-Dawley, Spinal Cord Injuries},
	issn = {1522-1598},
	doi = {10.1152/jn.00756.2013},
	url = {http://www.ncbi.nlm.nih.gov/pubmed/24371288},
	author = {Yi Chen and Lu Chen and Liu, Rongliang and Wang, Yu and Xiang Yang Chen and Jonathan Wolpaw}
}
@article {3389,
	title = {The simplest motor skill: mechanisms and applications of reflex operant conditioning.},
	journal = {Exerc Sport Sci Rev},
	volume = {42},
	year = {2014},
	month = {04/2014},
	pages = {82-90},
	abstract = {Operant conditioning protocols can change spinal reflexes gradually, which are the simplest behaviors. This article summarizes the evidence supporting two propositions: that these protocols provide excellent models for defining the substrates of learning and that they can induce and guide plasticity to help restore skills, such as locomotion, that have been impaired by spinal cord injury or other disorders.},
	keywords = {Animals, Conditioning, Operant, H-Reflex, Humans, Motor Skills, Muscle, Skeletal, Neuronal Plasticity, Reflex, Spinal Cord, Spinal Cord Injuries},
	issn = {1538-3008},
	doi = {10.1249/JES.0000000000000010},
	url = {http://www.ncbi.nlm.nih.gov/pubmed/24508738},
	author = {Thompson, Aiko K and Jonathan Wolpaw}
}
