Clinical Neurophysiology 112 (2001) 1575±1585

www.elsevier.com/locate/clinph
Review

Excitability of human axons

David Burke a,*, Matthew C. Kiernan a,b, Hugh Bostock b
a
Department of Neurology, Prince of Wales Hospital and Prince of Wales Medical Research Institute, University of New South Wales,
Sydney, N.S.W., Australia
b
Sobell Department of Neurophysiology, Institute of Neurology, London, UK
Accepted 15 May 2001

Abstract
The excitability of human axons can be studied reliably using the technique of threshold tracking, which allows the strength of a test
stimulus to be adjusted by computer to activate a de®ned fraction of the maximal nerve or muscle action potential. The stimulus current that
just evokes the target response is considered the `threshold' for that response. More useful than the resting threshold are other indices of
axonal excitability derived from pairs of threshold measurements, such as refractoriness, supernormality, strength-duration time constant and
`threshold electrotonus' (i.e. the changes in threshold produced by long-lasting depolarizing or hyperpolarizing current pulses). Each of these
measurements depends on membrane potential and on other biophysical properties of the axons. Together they can provide new information
about the pathophysiology underlying abnormalities in excitability in neuropathy. q 2001 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Axonal excitability; Recovery cycle; Threshold electrotonus; Depolarization; Hyperpolarization

1. Introduction
When axons are diseased or damaged, disturbed axonal
excitability may result in the inability to maintain conduc-
tion of a meaningful impulse train (Bostock and Grafe,
1985; Burke et al., 1997; Inglis et al., 1998; Cappelen-
Smith et al., 2000; Kaji et al., 2000). Alternatively ectopic
activity may develop at a focus of hyperexcitability leading
to symptoms of paraesthesiae, or pain or fasciculation
(Lance et al., 1979; Ochoa and TorebjoÈrk, 1980; NystroÈm
and Hagbarth 1981; Culp and Ochoa, 1980; Nordin et al.,
1984; Waxman et al., 1999; Mogyoros et al., 2000). The
abnormalities of axonal excitability that underlie conduc-
tion block and ectopic impulse activity are not adequately
explored by routine nerve conduction studies. In routine
diagnostic studies, only latency or conduction velocity can
be measured accurately but, while such measurements may
be very useful in de®ning pathology, they provide little
insight into underlying disease mechanisms because a
number of morphological and functional changes can
prolong latency (Table 1). Increasingly the technique of
`threshold tracking' is being used in research and clinical
studies on large myelinated axons (Bostock et al., 1998;
* Corresponding author. Prince of Wales Medical Research Institute,
Barker Street, Randwick, N.S.W. 2031, Australia. Tel.: 161-2-9382-
2671; fax: 161-2-9382-2724.
E-mail address: d.burke@unsw.edu.au (D. Burke).
1388-2457/01/$ - see front matter q 2001 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 1388-245 7(01)00595-8
Kiernan et al., 2000), and Table 2 lists some of the neuro-
pathic disturbances that have been so studied. This paper
reviews some of the determinants of the excitability of large
myelinated axons and the mechanisms underlying the excit-
ability properties that can be studied in vivo in human
subjects.
2. Threshold tracking methods
The electrical excitability of an axon is de®ned by the
threshold current that just excites it. Threshold determina-
tion is a trial-and-error process, and best achieved using a
computer to control the output of a current source, depend-
ing on the response of the axon or group of axons stimu-
lated. The interested reader is referred to a recent review of
`threshold tracking' for a detailed discussion of the techni-
que (Bostock et al., 1998). For single axons, `threshold' is
estimated as the stimulus current that activates the axon
50% of the time. However, in clinical practice, tracking
the threshold of a compound sensory or motor action poten-
tial is usually more rewarding than tracking the threshold for
a single axon. With compound potentials, the computer is
set to estimate the stimulus current necessary to produce a
target potential that is a speci®c % of maximum.
Commonly, the target size is set at 30, 40 or 50% of the
maximal compound action potential because these sizes fall
on the steeply rising phase of the stimulus/response curve
CLINPH 2001024
1576 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585

Table 1 duration conditioned by a supramaximal stimulus using a 7

Causes of conduction slowing ms interstimulus interval. This particular set of stimuli
Morphological variations or changes would allow several different excitability parameters
Axonal tapering; axonal attenuation at sites of constriction; axonal described in this review (threshold, refractoriness at 2 ms,
regrowth supernormality at 7 ms, strength-duration time constant) to
Demyelination be followed at much the same time. Clearly, the time taken
Nodal displacement and intussusception
before a particular threshold estimate is updated will be
Remyelination with short internodes
longer the greater the number of stimuli and the longer
Functional (changes in axonal excitability) the interval between successive stimuli. In the above exam-
Cooling ple, each excitability parameter would be updated every 5 s
Axonal hyperpolarization if the interval between successive stimuli was 1 s.
Axonal depolarization
For recording `threshold electrotonus' (as in Figs. 2 and
4A) repeated comparisons are made between the resting
threshold and the threshold at different times after the start
of long-lasting subthreshold depolarizing and hyperpolariz-
(see Kiernan et al., 2000, 2001d). If a manoeuvre changes
ing currents. The accuracy of each threshold estimate (i.e.
the size of the maximal potential, it is necessary to measure
for each value of the delay between the start of the condi-
the maximal response regularly and to change the size of the
tioning current and the test stimulus) depends on the number
target potential tracked by the computer accordingly. This
of stimuli delivered, and on the change in threshold since the
can be achieved by appropriate threshold-tracking software
last threshold estimate. The QTRAC software allows the
(e.g. QTRAC, qInstitute of Neurology, London, UK).
conditioning-test delay to be advanced only when a speci-
As mentioned later, the absolute value of the threshold
®ed number of stimuli provide acceptable threshold esti-
current usually provides little information, because it is vari-
mates. The recording of recovery cycles (as in Figs. 3 and
able within a subject and between subjects. More informa-
4B) is similar, except that the conditioning stimuli are brief
tion is provided by excitability parameters obtained by
and supramaximal, instead of long-lasting and subthreshold.
comparing two threshold estimates (e.g. strength-duration
To allow accurate measurement of the responses to the test
time constant, which can be estimated from the thresholds
stimuli, the response to the supramaximal conditioning
to 1 ms and 0.1 ms stimuli). The computer can control the
stimulus alone is subtracted from the response to each
delivery of different stimuli (or stimulus combinations) in a
conditioning 1 test pair before measurement. The threshold
regularly recurring sequence, with successive stimuli deliv-
electrotonus and recovery cycle recordings in Fig. 4 each
ered at intervals of about 1 s. For example, different stimuli
took between 3 and 3.5 min, with stimuli presented every
might be (i) a supramaximal stimulus, (ii) an unconditioned
0.8 s.
test stimulus of 0.1 ms duration, (iii) an unconditioned test
stimulus of 1.0 ms duration, (iv) a test stimulus of 0.1 ms
duration conditioned by a supramaximal stimulus using a 2
ms interstimulus interval, and (v) a test stimulus of 0.1 ms 3. Axonal excitability depends on nodal and internodal
ion channels
Table 2
Axonal excitability studies in neuropathic disorders The action potential of human myelinated axons can be
modelled successfully using only the properties of transient
Disorder References Na 1 channels (Schwarz et al., 1995). Other channels are
Auto-immune neuropathy
activated during and after the action potential. Some contri-
Acquired neuromyotonia Maddison et al., 1999; Kiernan bute to resting membrane potential and thereby determine
et al., 2001c the threshold for action potential generation. Ion channels
Diabetic polyneuropathy Weigl et al., 1989; Strupp et al., are not evenly distributed along a myelinated axon (Fig. 1).
1990; Horn et al., 1996 The density of Na 1 channels at the node of Ranvier is ,30
Demyelinating polyneuropathies
Multifocal motor neuropathy Kaji et al., 2000
times the density on the internodal membrane. The interno-
Chronic in¯ammatory Cappelen-Smith et al., 2000 dal density is too low for action potential propagation and,
demyelinating polyneuropathy in demyelinated axons, the action potential is generated only
Toxic neuropathies at the node unless the density of sodium channels on the
Taxol/cisplatin Hanauske et al., 1995; Schilling internodal membrane increases.
et al., 1997
Mononeuropathies
Recent evidence suggests that, although 6 types of Na 1
Carpal tunnel syndrome Mogyoros et al., 1997a; Kiernan channel are expressed in the peripheral nervous system
et al., 1999 (Goldin, 1999; Goldin et al., 2000; Waxman et al., 1999),
Neuronopathy only one (Nav1.6) is found at nodes of Ranvier (Caldwell et
Amyotrophic lateral sclerosis Bostock et al., 1995; Horn et al., al., 2000). Nevertheless two functionally distinct types of
1996; Mogyoros et al., 1998a,b
sodium current can be distinguished. The classical `transi-
 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585
Fig. 1. Distribution of some conductances. Different channels are not distributed evenly along the membrane of myelinated ®bres, as described further in the
text.
ent' Na 1 current (INat in Fig. 1) is activated rapidly by
membrane depolarization and then inactivates, so that
further Na 1 ions cannot pass through the channel no matter
how much the membrane is depolarized. About 98% of the
sodium current behaves in this way. `Persistent' Na 1 current
(INap) is activated equally rapidly but at membrane potentials
that are ,10±20 mV more negative. At the most negative
potentials over which the current activates, inactivation is
minimal, giving rise to a persistent inward leak of sodium
ions at the resting potential, a potentially destabilizing prop-
erty. Both `persistent' and `transient' components of the
Na 1 current have been recorded in rat dorsal root ganglia
cells (Baker and Bostock, 1997, 1998; Kiernan et al.,
2001a), and excitability studies indicate that both are
present in human peripheral nerve (Bostock and Rothwell,
1997).
There are many types of K 1 channel on axons (Vogel and
Schwarz, 1995; Reid et al., 1999), but it is convenient for
clinical purposes to restrict discussion to two groups that are
dependent on membrane potential, those with fast kinetics
and those with slow kinetics. There are few fast K 1 channels
(K 1f in Fig. 1) at the human node of Ranvier such that, when
modelling the action potential, K 1 channels can be ignored
(Schwarz et al., 1995). In mammalian axons repolarization
is achieved by inactivation of Na 1 channels and current leak
to the internode (Ritchie, 1995). Fast K 1 channels are
located in a tight band in the paranodal region where they
contribute to the resistance of the internodal membrane and
limit the depolarizing afterpotential responsible for the
supernormal period (see later). Slow K 1s channels (Ks in
1577
Fig. 1) have a density at the node 25 times that at the inter-
node, but their kinetics are too slow to allow them to affect
the action potential directly. They help determine resting
membrane potential, contribute to accommodation to depo-
larizing stimuli, and are largely responsible for the late
subnormal period and for the hyperpolarization that follows
a brief train of impulses (see below).
There are channels on the internode that are activated
slowly by hyperpolarization, pass both Na 1 and K 1 ions,
and produce accommodation to the hyperpolarization
(hence the term `inward recti®cation'). The conductance is
now usually referred to as IH, the `hyperpolarization-acti-
vated cation conductance' (Pape, 1996), and its biological
role is probably to limit the hyperpolarization that occurs
when axons conduct trains of impulses.
4. The internode is not isolated and its properties set the
resting membrane potential
Changes in potential of the node spread to the internode,
but slowly because of the resistance of the myelin sheath
and the large capacitance of the internodal axolemma. This
results in slow activation/deactivation of voltage-dependent
channels on the internodal membrane. Although Na 1 chan-
nel density is insuf®cient for the internodal membrane to
generate an action potential, the changes in resistance of
the internodal membrane and in the current stored on it
will affect the behaviour of the node (for review see
Baker, 2000). Approximately 99.9% of axonal membrane
1578 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585

is internodal so that, despite the lower channel densities,
there are many more channels on the internode than on
the node.
Resting membrane potential is determined by those chan-
nels that are open at or near rest (both voltage-dependent
and voltage-independent) and by the activity of the Na 1/K 1
pump, and this implies that it is largely determined by the
properties of the internodal membrane. The major contribu-
tors are probably slow and fast K 1 channels, persistent Na 1
channels, and the Na 1/K 1 pump.
5. Some internodal conductances can be studied using
`threshold electrotonus'
The technique that provides most insight into internodal
conductances in human subjects in vivo is `threshold elec-
trotonus' (Bostock and Baker, 1988). This term was coined
for the changes in threshold produced by long-lasting DC
pulses (Fig. 2), because under most circumstances, the
changes in threshold largely parallel the underlying electro-
tonic changes in membrane potential. Conventionally,
threshold electrotonus is plotted such that an increase in
excitability (i.e. a threshold reduction) produces an upwards
de¯ection and a decrease in excitability a downward de¯ec-
tion. This convention was adopted so that changes in thresh-
old electrotonus would resemble the underlying changes in
membrane potential (Bostock and Baker, 1988).
5.1. There is accommodation to long-lasting depolarizing
current pulses
In response to depolarizing current pulses, there is an
initial fast phase of threshold electrotonus that is almost
instantaneous and is proportional to the applied current
(the `F' phase). This is followed by further depolarization
that develops slowly over some tens of milliseconds as the
current spreads to and depolarizes the internodal membrane
(the `S1' phase, producing the upward de¯ections in Fig. 2).
The threshold decrease (i.e. the extent of depolarization)
reaches a peak ,20 ms after the onset of the current
pulse, dependent on its strength, and then threshold starts
to return slowly towards the control level. This lessening of
the degree of depolarization is due to activation of a hyper-
polarizing conductance with slow kinetics and is called
`S2.' The use of K 1 channel blocking agents indicates
that the slow accommodative process is due to activation
of slow K 1 channels, which are located on both the node

Fig. 2. Threshold electrotonus of sensory and motor axons in the ulnar nerve at the wrist. Changes in the threshold stimulus current for the target potential
produced by polarizing currents lasting 300 ms, the intensity of the polarizing currents being 40% of threshold in the depolarizing direction and 40% and 80%
of threshold in the hyperpolarizing direction for both sets of ®bres. A reduction in threshold produced by depolarizing current is plotted as an upward de¯ection,
so that the waveforms look like the underlying electronic potentials. The different components of threshold electrotonus are labelled on panel A. The only
difference in threshold electrotonus of sensory and motor ®bres is in S3, the inward recti®cation due to IH. Each panel shows the mean data for 8 subjects ^ 1
standard error. From Bostock et al. (1994), with permission.
 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585 1579

and the internode (Baker et al., 1987; Bostock and Baker,
1988; Baker and Bostock, 1989). When the DC pulse is
terminated, threshold increases rapidly, and there is then a
slow overshoot before it gradually recovers to the control
level. The slow overshoot is due to passive repolarization of
the internodal membrane, while the ®nal recovery to the
control level is due to the deactivation of the K 1 conduc-
tance.
5.2. There is accommodation to long-lasting
hyperpolarizing current pulses
7. Excitability properties re¯ect membrane potential
It is not possible to measure membrane potential in intact
human axons, but it is possible to obtain indirect evidence
about membrane potential by studying excitability indices
that are dependent on membrane potential. Each of the
indices below can be altered by factors other than membrane
potential, but it is a reasonable conclusion that membrane
potential is different when these indices undergo changes in
the appropriate direction and by the appropriate extent.

With long-lasting hyperpolarizing DC pulses, there is 7.1. Threshold

again a fast threshold change that increases threshold, During many acute manoeuvres, the stimulus current
proportionally to the applied current, analogous to the necessary to activate an axon or to produce a compound
comparable phase with depolarizing currents (the `F' potential of ®xed size (i.e. the threshold for the potential)
phase). Then threshold continues to increase as the hyper- can be used as a surrogate marker of membrane potential.
polarization spreads to the internode (producing the down-
ward de¯ections in Fig. 2). This `S1' phase is not the mirror
image of the S1 phase with depolarizing currents because
hyperpolarization closes internodal K 1 channels (and this
will increase internodal resistance and the size of S1) while
depolarization activates internodal K 1 channels (and this
will limit the size of S1). At ,100 ms after the start of
the hyperpolarizing current pulse, S1 reaches a maximum
and threshold begins to decrease towards the control level.
This accommodative `S3' phase produces inward recti®ca-
tion and is due to activation of IH. Although IH has slow
activation and deactivation kinetics, it is activated and
affects threshold earlier than 100 ms (where S1 peaks):
without IH, the hyperpolarizing threshold increase would
be even greater. On termination of the hyperpolarizing DC
pulse, threshold rapidly decreases and then slowly under-
shoots the resting threshold until IH deactivates and the slow
K 1 conductance reactivates.

6. Excitability ¯uctuates after an action potential

Following an action potential, large myelinated axons are

absolutely refractory for 0.5±1.0 ms, during which they
cannot generate another action potential no matter how
strong the depolarizing stimulus. The axons are then rela-
tively refractory for some 3±4 ms, during which a stronger
than normal depolarizing stimulus is required to generate an
action potential. As refractoriness subsides, axons pass into
a phase of supernormality (or superexcitability) during
which the stimulus necessary to generate an action potential Fig. 3. The recovery of excitability of sensory and motor axons in the
median nerve at the wrist following a single supramaximal conditioning
is less than at rest, the mechanisms for which are discussed
stimulus. Panel A shows the data for compound sensory action potentials of
later (Fig. 3). This phase peaks at ,7 ms in cutaneous 3 different sizes. Panel B shows the equivalent data for motor axons. In this
afferents of the sural and median nerves and in motor ®gure a reduction in excitability is plotted upwards. At short-conditioning
axons of the peroneal and median nerves (Kiernan et al., test intervals, the axons fall within the relatively refractory period, and
1996; Lin et al., 2000a; Kuwabara et al., 2000). Thereafter threshold is increased. At 3±4 ms, axons enter the supernormal period,
and less current is required to activate them, such that threshold is lower
axons become less excitable again as they pass into the late
than control for ,20 ms, when axons enter the late subnormal period. Note
subnormal (or subexcitable) period, returning to resting that the threshold excursions are smaller for sensory ®bres than for motor,
excitability slowly, 100±150 ms after the conditioning but that the changes are similar for compound potentials of different size.
discharge. From Kiernan et al. (1996), with permission.
1580 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585
As the membrane depolarizes, the threshold current neces-
sary to produce the target potential decreases, and as the
membrane hyperpolarizes threshold increases. However,
because threshold varies considerably between subjects
due to geometric factors, resting threshold does not provide
useful information about resting membrane potential. Such
information can instead be obtained by comparing threshold
before and after a conditioning nerve impulse, or before and
during the application of a polarizing current.
Apart from the issue of intersubject variability, changes
in excitability do not always parallel changes in membrane
potential. Membrane depolarization reduces the voltage
change necessary to activate Na 1 channels, but it also inac-
tivates Na 1 channels, reducing the number available for
action potential generation. The greater the depolarization,
the more important the effect on Na 1 channel inactivation
becomes, so that with progressive depolarization, such as
occurs during ischaemia, the reduction in threshold does not
continue inde®nitely, but reaches a limit and then starts to
increase, ultimately resulting in depolarizing block. In addi-
tion, ischaemia produces a voltage-independent block of
Na 1 channels, possibly due to intracellular acidosis, and
this accentuates the discrepancy between excitability (or
threshold) and membrane potential (Grosskreutz et al.,
1999, 2000). A further example is the increase in axonal
excitability that occurs during hyperventilation, which is
probably due to changes in extracellular pH (rather than
extracellular Ca 21 concentration) and with which changes
in membrane potential are secondary rather than primary
(Mace®eld and Burke, 1991; Mogyoros et al., 1997b).
7.2. Refractoriness
It is impossible in human subjects to measure the extent
or duration of absolute refractoriness because there is a
limitation on the stimulus that can be delivered to a patient.
Relative refractoriness has been measured in two ways: as
the increase in current required to produce the target poten-
tial at a ®xed conditioning-test interval, usually 2 ms (e.g.
Burke et al., 1998; Bostock et al., 1998), or as the duration
of the relatively refractory period (normally 3±4 ms at skin
temperatures of 32±348C; Kiernan et al., 2000, 2001b). The
former is well-suited for following the evolution of a
number of indices of axonal excitability during experimen-
tal manoeuvres, such as ischaemia and membrane polariza-
tion (Mogyoros et al., 1997b; Burke et al., 1998). However,
extreme hyperpolarization can cause supernormality to
intrude into this conditioning-test interval (Burke et al.,
1998), just as extreme depolarization can cause refractori-
ness to intrude into conditioning-test intervals normally
associated with maximal supernormality (Mogyoros et al.,
1997b; Burke et al., 1998). These problems do not occur
when refractoriness is estimated using the duration of the
relatively refractory period, but this requires measurements
at multiple conditioning-test intervals.
Refractoriness changes with membrane potential because
this alters Na 1 channel inactivation. It is generally assumed
that, at resting membrane potential, some 30% of Na 1 chan-
nels are inactivated (Hodgkin and Huxley, 1952; see
Schwarz et al., 1995). Hyperpolarizing shifts in membrane
potential remove this `resting' inactivation and decrease the
extent of refractoriness. Conversely, depolarizing shifts in
membrane potential will increase the extent of inactivation
and thereby increase refractoriness (Fig. 4). Unlike most
other excitability parameters, refractoriness is extremely
temperature sensitive, however measured (Burke et al.,
1998; Kiernan et al., 2001b). It is therefore essential to
take temperature into account if refractoriness is to be
used as an index of membrane potential.
7.3. Supernormality
When the node depolarizes to produce an action potential,
current is stored on the internodal membrane and then
discharges through high resistance pathways under or
through the myelin. This produces the negative (or depolar-
izing) afterpotential that is responsible for the phase of
supernormal excitability (Barrett and Barrett, 1982; Blight,
1985; Bowe et al., 1987). The extent of supernormality
varies with membrane potential because this alters the resis-
tance of the paranodal membrane (by voltage-dependent
effects on paranodal K 1 channels; David et al., 1992,
1995). However, factors that alter myelin resistance (such
as paranodal demyelination) should also alter the extent of
supernormality.
Depolarization of the internodal membrane opens para-
nodal K 1 channels and this reduces the resistance of the
internodal membrane, and thereby the size of the depolariz-
ing afterpotential and the extent of supernormality (Fig. 4).
Hyperpolarization closes paranodal K 1 channels, increases
internodal membrane resistance, and thereby increases the
depolarizing afterpotential and the extent of supernormality.
Supernormality and refractoriness are both more sensitive
than the resting threshold to changes in membrane potential,
but whereas the potential dependence of refractoriness
depends primarily on the properties of nodal Na 1 channels,
the potential dependence of supernormality depends primar-
ily on paranodal K 1 channels.
7.4. Strength-duration time constant
The strength-duration time constant (t SD) is a measure of
the rate at which the threshold current for a target potential
declines as stimulus duration is increased, and in the formu-
lation of Weiss (1901) it equates to chronaxie. Rheobase is
the threshold for a stimulus that can be in®nitely long, and
both are properties of the nodal membrane. The voltage-
dependence of these properties is due to conductances that
are active near threshold, particularly a rapidly activating
depolarizing conductance that inactivates slowly, if at all
(Bostock and Rothwell, 1997). These properties are those
of persistent Na 1 currents, and computer modelling of the
behaviour of human sensory and motor axons suggests that
 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585 1581

Fig. 4. The effects of changing membrane potential on threshold electrotonus (A) and the recovery cycle (B). With background depolarization, there is a
collapsing in (`fanning in') of the threshold electrotonus waveform (panel A) and an increase in refractoriness and a decrease in supernormality (panel B). With
background hyperpolarization, the reverse changes occur. In each panel, the behaviour at rest is the middle trace, there being 4 levels of background
depolarization and 4 of hyperpolarization. From Kiernan and Bostock (2000), with permission.

these currents constitute ,2.5% of the total Na 1 current on
sensory axons and ,1% on motor axons (Bostock and
Rothwell, 1997). Increasing the fraction of Na 1 current
that is persistent (or depolarizing the node) will produce a
longer t SD and lower rheobase. The longer t SD of sensory
axons is accompanied by a lower rheobase (,50%) than in
motor axons, and this difference in rheobase results in less
current being required to maintain conduction in critically
impaired sensory axons than equivalently impaired motor
axons.
7.5. Threshold electrotonus
There are substantial changes in threshold electrotonus
when axons are depolarized or hyperpolarized (Fig. 4; see
Baker and Bostock, 1989; Horn et al., 1996; Kaji, 1997;
Kiernan and Bostock, 2000). With background membrane
hyperpolarization, there is an increase in the S1 phase in
both the depolarizing and hyperpolarizing directions,
because the resistance of the internodal membrane is
increased due to the closure of paranodal and internodal
K 1 channels. This has been termed `fanning out' by Kaji
(1997). Conversely, background membrane depolarization
decreases the resistance of the internode because it activates
paranodal and internodal K 1 channels, thereby decreasing
S1 with both depolarizing and hyperpolarizing currents, and
producing an appearance of `fanning in' (Fig. 4).
7.6. Excitability parameters and membrane potential
The extent of the dependence of each of these parameters
on membrane potential has been explored in studies that
measured the effects of intermittent DC polarizing currents
(Burke et al., 1998) or of continuous DC polarizing current
and ischaemia on axonal excitability (Kiernan and Bostock,
2000), for sensory and motor axons respectively. In the
latter study, a depolarizing current of 1 mA (estimated to
depolarize the axons by about 4 mV) resulted in large
changes in the relatively refractory period (increased by
37%), supernormality (decreased by 82%), and threshold
electrotonus (fanning in by 18% in the depolarizing phase
and 71% in the hyperpolarizing phase). There was a smaller
change in strength-duration time constant (increased by
5%). Similar magnitudes of change in excitability were
shown when membrane potential was altered indirectly
using ischaemia. The patterns of change in these different
excitability parameters should provide a useful indication of
changes in resting membrane potential in patients.
8. Axons are not identical
The sensitivity of an axon to stresses such as ischaemia
differs along the course of the axon (Bostock et al., 1991a)
but few biophysical differences have been identi®ed so far at
different sites along the same nerve (Mogyoros et al., 1999;
Kuwabara et al., 2000). However, there is good evidence for
subtle biophysical differences between axons of different
modality, perhaps because their discharge rates and
discharge patterns differ.
8.1. Differences between sensory and motor axons
When compared with upper-limb cutaneous afferents,
1582 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585
upper-limb motor axons undergo less refractoriness, super-
normality and late subnormality following a single
discharge (Kiernan et al., 1996; see Fig. 3), have a shorter
strength-duration time constant and a higher rheobase
(Panizza et al., 1994; Mogyoros et al., 1996; Bostock and
Rothwell, 1997), and probably express a lesser persistent
Na 1 conductance (Bostock and Rothwell, 1997) and less
inward recti®cation (IH) (Bostock et al., 1994; see Fig. 2).
As a result of some of these differences, it has been argued
that motor axons are more likely to undergo conduction
block than cutaneous afferents but less prone to become
ectopically active (Burke et al., 1997; Bostock et al.,
1998). For example, the difference in IH would render
motor axons less protected from hyperpolarization and,
indeed, there is evidence that activity-dependent hyperpo-
larization is greater in motor axons than sensory for equiva-
lent discharge rates (Vagg et al., 1998). When action
potential generation is precarious, the higher rheobase of
motor axons suggests that motor axons may require more
current to keep them conducting than sensory axons.
8.2. Differences between different sensory axons and
different motor axons
Comparison of measurements of late subnormality and
threshold electrotonus suggest that cutaneous afferents in
the sural nerve have lesser nodal and internodal slow K 1
conductances and less IH than cutaneous afferents in the
median nerve (Lin et al., 2000a,b). These differences
could predispose sural afferents to undergo dysfunction
before median afferents, and this may be a factor in why
acquired polyneuropathies are usually more severe distally
in the lower limbs. Peroneal motor axons probably also
express a lesser slow K 1 conductance than median motor
axons but IH appears to be similar (Kuwabara et al., 2000,
2001).
9. Conducting trains of impulses alters axonal
excitability
As illustrated in Fig. 3, the generation of an action poten-
tial at the node of Ranvier sets up a sequence of oscillating
changes in membrane potential which, following a single
action potential, are commonly referred to as the recovery
cycle. Trains of impulses result in summation of these
effects, compensatory mechanisms to correct the altered
distribution Na 1 and K 1 ions on either side of the
membrane (e.g. activation of the Na 1/K 1 pump) and the
secondary effects of processes designed to minimize unto-
ward effects of pump activation (e.g. activation of IH to
reduce the pump-induced hyperpolarization).
9.1. Axons hyperpolarize when they conduct brief trains of
impulses
The changes induced during the recovery cycle also occur
when trains of impulses are conducted, but only the slow
changes due to the late subnormal phase are cumulative.
This causes axonal hyperpolarization which is maximal
with some 10±20 impulses in the train and which decays
back to resting level over some 100±150 ms (Bergmans,
1970; Taylor et al., 1992; Miller et al., 1995). This decrease
in excitability was termed H1 by Bergmans (1970) because
it seems to correlate with the ®rst positive afterpotential (P1)
described by Gasser (1935). In median cutaneous afferents,
H1 increases threshold by some 40%, but for sural afferents
the threshold increase is less, some 20±30% (Lin et al.,
2000a). Given that H1 is largely due to a slow K 1 conduc-
tance (Baker et al., 1987), this provides some evidence for a
difference in nodal slow K 1 channels for median and sural
afferents. The hyperpolarization caused by H1 is probably
too brief to cause conduction block, but it is suf®ciently
strong that it could act as a rate-limiting mechanism for
diseased axons.
9.2. Axons undergo long-lasting hyperpolarization
following prolonged impulse trains
Impulse trains that last a few seconds will produce an
accumulation of Na 1 ions inside the axon and K 1 ions
outside the axon, and this altered distribution stimulates
the Na 1/K 1 pump (Fig. 5). However, the pump is `electro-
genic': the ion swap is not balanced, and pump activity
therefore results in axonal hyperpolarization. The term
`H2' was coined by Bergmans (1970) to describe the result-
ing threshold change because it seems analogous to the P2
positive afterpotential described by Gasser (1935).
In human axons, the membrane hyperpolarization
increases in depth with the number of pulses in the train
and then reaches a plateau, further impulses prolonging
the time that threshold remains elevated following cessation
of the impulse train (Bergmans, 1970; Bostock and Berg-
Fig. 5. Mechanisms of activity-dependent conduction block.
 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585
mans, 1994; Kiernan et al., 1997a). Other processes become
more important the longer the impulse train, particularly
with unnaturally long high-frequency trains lasting 5±30
min (Bergmans, 1970; Applegate and Burke, 1989; Bostock
et al., 1991b; Bostock and Bergmans, 1994; Kiernan et al.,
1997a,b). These changes can result in ectopic impulse activ-
ity in sensory and motor axons but are outside the scope of
this review.
Natural activity can produce substantial axonal hyperpo-
larization (Fig. 6), and this appears to be greater for motor
axons than sensory, probably because the former have less
IH (see earlier). A maximal voluntary contraction of abduc-
tor pollicis brevis lasting only 15 s increases the threshold of
median motor axons (measured using 1-ms test pulses) by
15±20% and contraction for 1 min increases threshold by
Fig. 6. Activity-dependent hyperpolarization of motor axons following
contractions of different duration. The ®gure shows the changes in thresh-
old, of median motor axons at the wrist following maximal voluntary
contractions of abductor pollicis brevis for 15 s, 30 s and 60 s. The contrac-
tions began at 5 min on the horizontal axis, and resulted in an increase in the
current required to produce the target compound muscle action potential of
the thenar muscles. Following the 60-s contraction, the increase in current
was ,40% and it took 10±15 min to decay to control values. A smaller but
signi®cant increase followed the 15-s contraction. Mean data for 6 subjects.
From Vagg et al. (1998), with permission.
1583
,40% (Fig. 6; Vagg et al., 1998). Importantly the hyperpo-
larization may take some 10±15 min to decay to pre-
contraction levels on cessation of the voluntary effort. The
extent and duration of the activity-dependent hyperpolariza-
tion is insuf®cient to jeopardize normal impulse traf®c in
healthy axons, but it can trigger conduction block in demye-
linated axons of patients with chronic in¯ammatory demye-
linating polyneuropathy and multifocal motor neuropathy
(Fig. 5; see Cappelen-Smith et al., 2000; Kaji et al., 2000).
10. Of what clinical value are measurements of axonal
excitability?
As a clinical tool, measurements of axonal excitability are
still in their infancy, the physiological and technical factors
that can affect the measurements are being explored, clini-
cally useful protocols are being developed, and their varia-
bility in normal subjects is being assessed. To be useful
clinically, testing should assess multiple indices relatively
quickly, so that the procedures can be used, when appropri-
ate, to supplement conventional nerve conduction studies.
This rationale underlies the development of a rapid testing
protocol that assesses stimulus/response curves, strength-
duration properties, threshold electrotonus and recovery
cycle for motor axons in ,10 min (Kiernan et al., 2000).
A similar but, of necessity, slightly longer protocol has been
developed for sensory axons (Kiernan et al., 2001d).
However, at the moment, studies of axonal excitability
have been used in only a limited number of disease
processes (Table 2), generally to provide insight into the
underlying pathophysiology, rather than diagnosis. For
example, in patients with diabetic neuropathy, the decrease
in threshold that occurs during ischaemia and the increase in
threshold that occurs on release of ischaemia are less than in
healthy nerve (Weigl et al., 1989; Strupp et al., 1990). This
is the basis of the so-called `ischaemic resistance' of
diabetic nerve and, as a result, diabetic patients experience
fewer paraesthesiae during and after ischaemic insults. The
threshold abnormalities correlate with the degree of diabetic
control. In addition, studies using threshold electrotonus
have demonstrated that there is less IH in diabetic sensory
and motor axons than normal (Horn et al., 1996). In patients
with motor neurone disease, there is evidence for decreased
K 1 conductances (Bostock et al., 1995; Horn et al., 1996)
and a longer t SD, perhaps indicating increased INap on motor
axons (Mogyoros et al., 1998a,b). Both of these changes
would increase axonal excitability. A recent ®nding with
major implications for diagnostic practice has been the
demonstration that conventional measurements of conduc-
tion block in demyelinating neuropathies, using low stimu-
lation rates, are likely to underestimate the true extent of
conduction block experienced by the patient (Cappelen-
Smith et al., 2000; Kaji et al., 2000). Such measurements
would be improved by testing before and after a standar-
dized voluntary contraction.
1584 D. Burke et al. / Clinical Neurophysiology 112 (2001) 1575±1585
Acknowledgements
This work was supported by the National Health and
Medical Research Council of Australia. MCK was recipient
of a C.J. Martin/R.G. Menzies Travelling Fellowship of the
National Health and Medical Research Council of Australia.
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