Noninvasive human brain stimulation

Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research

This article is based on a consensus conference, which took place in Certosa di Pontignano, Siena (Italy) on March 7-9, 2008, intended to update the previous safety guidelines for the application of transcranial magnetic stimulation (TMS) in research and clinical settings. Over the past decade the scientific and medical community has had the opportunity to evaluate the safety record of research studies and clinical applications of TMS and repetitive TMS (rTMS). In these years the number of applications of conventional TMS has grown impressively, new paradigms of stimulation have been developed (e.g., patterned repetitive TMS) and technical advances have led to new device designs and to the real-time integration of TMS with electroencephalography (EEG), positron emission tomography (PET) and functional magnetic resonance imaging (fMRI). Thousands of healthy subjects and patients with various neurological and psychiatric diseases have undergone TMS allowing a better assessment of relative risks. The occurrence of seizures (i.e., the most serious TMS-related acute adverse effect) has been extremely rare, with most of the few new cases receiving rTMS exceeding previous guidelines, often in patients under treatment with drugs which potentially lower the seizure threshold. The present updated guidelines review issues of risk and safety of conventional TMS protocols, address the undesired effects and risks of emerging TMS interventions, the applications of TMS in patients with implanted electrodes in the central nervous system, and safety aspects of TMS in neuroimaging environments. We cover recommended limits of stimulation parameters and other important precautions, monitoring of subjects, expertise of the rTMS team, and ethical issues. While all the recommendations here are expert based, they utilize published data to the extent possible.

Brain stimulation in the study and treatment of addiction

Addiction is a devastating and chronically relapsing disorder. Repeated drug administration induces neuroadaptations associated with abnormal dopaminergic activity in the mesocorticolimbic circuitry, resulting in altered cortical neurotransmission and excitability. Electrical stimulation of specific brain regions can be used in animal models and humans to induce local activation or disruption of specific circuitries or alter neuronal excitability and cause neuroadaptations. Non-surgical stimulation of specific brain regions in human addicts can be achieved by transcranial magnetic stimulation (TMS). TMS is used for transient stimulation or disruption of neural activity in specific cortical regions, which can be used to assess cortical excitability, and to induce changes in cortical excitability. Moreover, it is suggested that repeated stimulation can cause long-lasting neuroadaptations. Therefore, TMS paradigms were used in some studies to assess the presence of altered cortical excitability associated with chronic drug consumption, while other studies have begun to assess the therapeutic potential of repetitive TMS. Similarly, transcranial direct current stimulation (tDCS) is used to modulate neuronal resting membrane potential in humans and alter cortical excitability. The current review describes how these brain stimulation techniques have recently been used for the study and treatment of addiction in animal models and humans.

Repetitive transcranial magnetic stimulation over the right dorsolateral prefrontal cortex decreases valuations during food choices

Several studies have found decision-making-related value signals in the dorsolateral prefrontal cortex (DLPFC). However, it is unknown whether the DLPFC plays a causal role in decision-making, or whether it implements computations that are correlated with valuations, but that do not participate in the valuation process itself. We addressed this question by using repetitive transcranial magnetic stimulation (rTMS) while subjects were involved in an economic valuation task involving the consumption of real foods. We found that, as compared with a control condition, application of rTMS to the right DLPFC caused a decrease in the values assigned to the stimuli. The results are consistent with the possibility that the DLPFC plays a causal role in the computation of values at the time of choice.

Long-lasting inhibition of cerebellar output

OBJECTIVE

The cerebellar influence on the motor cortex output is exerted mostly though the cerebellothalamocortical pathway (CTC). One way to explore this pathway is by the means of transcranial magnetic stimulation (TMS). A single-pulse conditioning magnetic stimulation delivered over the lateral cerebellum was shown to diminish the excitability of the contralateral motor cortex 5 milliseconds later (cerebellocortical inhibition [CBI]), most likely through transynaptic activation of cerebellar Purkinje cells, which in turn inhibit the tonic activity of the CTC. Repetitive TMS (rTMS) delivered over the lateral cerebellum was shown to induce a long-lasting change of the cortical excitability, as well, but the mechanism and time course of this effect are still debated.

METHODS

We tested the time course of the effects of rTMS on the CBI in five paradigms: (1) 1 Hz rTMS, (2) continuous theta burst stimulation (cTBS), and (3) intermittent TBS (iTBS) over the right cerebellum, (4) 1 Hz rTMS over the cervical nerve roots, and (5) 1 Hz rTMS over the left cerebellum. Surface electromyography was recorded from the right first dorsal interosseous (FDI) and adductor digiti minimi. A double-cone coil was used for single-pulse cerebellar stimulation, whereas a figure-of-eight coil was used for the rTMS. The stimulus intensity was set at 90% of the M1 resting motor threshold for 1 Hz rTMS, and at 80% of the M1 active motor threshold for TBS. Both types of cerebellar stimulation were performed under magnetic resonance image (MRI)-guided neuronavigation centered over the right VIII B lobule, and stimulation intensities were adjusted for cerebellar cortex depth. A figure-of-eight coil was used for left motor cortex stimulation.

RESULTS

There was significant CBI suppression to the left motor cortex up to 30 minutes after the 900 stimuli of 1 Hz rTMS over either cerebellar hemisphere, and after 600 stimuli of cTBS over the right cerebellum, but not after 600 stimuli of iTBS over the right cerebellum, or after 900 of 1 Hz rTMS stimuli delivered over the cervical nerve roots. The 1 Hz rTMS over the left cerebellum significantly reduced the CBI in the right FDI 10 minutes after the end of the intervention. The amplitudes of the unconditioned cortical motor-evoked potentials were not significantly changed.

CONCLUSIONS

Our findings suggest that repetitive cerebellar stimulation operate at a cerebellar level, rather then at a cortical level.

Anodal transcranial direct current stimulation of the prefrontal cortex enhances complex verbal associative thought

The remote associates test (RAT) is a complex verbal task with associations to both creative thought and general intelligence. RAT problems require not only lateral associations and the internal production of many words but a convergent focus on a single answer. Complex problem-solving of this sort may thus require both substantial verbal processing and strong executive function capacities. Previous studies have provided evidence that verbal task performance can be enhanced by noninvasive transcranial direct current stimulation (tDCS). tDCS modulates excitability of neural tissue depending on the polarity of the current. The after-effects of this modulation may have effects on task performance if the task examined draws on the modulated region. Studies of verbal cognition have focused largely on the left dorsolateral prefrontal cortex (F3 of the 10-20 EEG system) as a region of interest. We planned to assess whether modulating excitability at F3 could affect complex verbal abilities. In Experiment 1 (anodal, cathodal, or sham stimulation over F3 with the reference electrode over the contralateral supraorbital region), we found a significant overall effect of stimulation condition on RAT performance. Post hoc tests showed an increase in performance after anodal stimulation (1 mA) compared to sham (p = .025) and to cathodal stimulation (p = .038). In Experiment 2 (either anodal stimulation at F3 or separately at its homologue F4), we replicated the anodal effect of the first study, but also showed that anodal stimulation of F4 had no effect on RAT performance. These data provide evidence that anodal stimulation of the left dorsolateral prefrontal cortex can improve performance on a complex verbal problem-solving task believed to require significant executive function capacity.

Combining TMS and fMRI: from 'virtual lesions' to functional-network accounts of cognition

Transcranial magnetic stimulation (TMS) is increasingly used in Cognitive Neuroscience to study functional contributions of a stimulated brain region to cognitive and perceptual processing. TMS-related behavioural effects are often interpreted as reflecting selective disruption of processing primarily within the stimulated region itself. This approach is now being extended by studies that combine TMS with concurrent neuroimaging measures, such as functional magnetic resonance imaging (fMRI). We discuss some recent combined TMS-fMRI studies and their implications for TMS investigations of cognition and perception. An emerging theme is that TMS does not affect only the stimulated region, but can also influence remote brain areas interconnected with the stimulation site. Such 'network' effects of TMS can be anatomically specific, but also context-dependent, changing with the current functional state of the targeted network rather than simply reflecting just fixed, context-invariant anatomical connectivity. Perceptual and behavioural effects of TMS may correspondingly involve TMS influences on remote interconnected brain regions, not solely on the stimulated region itself. Thus, TMS can now be used to study the consequences of functional interactions between the stimulated region and other parts of the network. This may lead beyond strictly modular views of brain function, that emphasize functional properties of single brain areas, towards new perspectives on how functional interactions between remote but interconnected brain regions may support perception and cognition.

Transcranial direct current stimulation modulates shifts in global/local attention

The effects of transcranial direct current stimulation on global/local attentional switching and feature processing were assessed. Direct current stimulation was applied to the left posterior parietal cortex in 14 healthy participants. A compound letter task was used to probe the feature processing and the switching of attention between global and local features. Results indicate that cathodal stimulation acutely degraded attentional switches during stimulation, and anodal stimulation persistently degraded local-to-global attentional switching for at least 20 min after stimulation. Direct current stimulation had no significant effects on global/local feature processing. These results support the functionality of left parietal cortex in attentional switch and represent the first successful modulation of global/local switching using exogenous brain stimulation.

Pharmacotherapy in stroke rehabilitation

BACKGROUND

Pharmacotherapy is commonly given to patients recovering from a stroke to prevent further complications (e.g. recurrent stroke, seizures) or enhance recovery. However, some drugs may have a negative impact on neuroplasticity.

OBJECTIVES

This review examines currently used drugs that are believed to promote recovery from motor and cognitive disturbances associated with stroke.

METHODS

Literature regarding the properties, efficacy, safety, and dosing of drugs used to promote recovery after stroke was reviewed.

RESULTS

The data on pharmacotherapy are insufficient to support a claim of significantly improved rehabilitation outcomes. Moreover, a growing body of evidence indicates that some agents can impair functional reorganization and slow the recovery process. However, a few chemicals are reported to be beneficial for stroke rehabilitation. The most promising are noradrenergic and dopaminergic agents, as well as several growth factors; these should be the future focus of extensive randomized clinical trials.

CONCLUSIONS

Currently there is no drug with proven efficacy in enhancing poststroke recovery.

Estimulação transcraniana por corrente direta: uma alternativa promissora para o tratamento da depressão maior?

OBJETIVO: Nos últimos anos, uma série de novos tratamentos somáticos não-farmacológicos vem sendo desenvolvida para o tratamento da depressão maior e de outros transtornos neuropsiquiátricos. Dentre esses, um dos mais promissores é a estimulação transcraniana por corrente direta. MÉTODO: Para a presente revisão da literatura consultou-se o PubMed entre janeiro de 1985 e fevereiro de 2009. Os artigos deveriam ser publicados em língua inglesa e deveriam abordar princípios gerais da estimulação transcraniana por corrente direta e sua utilização na depressão maior. DISCUSSÃO: Os protocolos atuais de estimulação transcraniana por corrente direta para o tratamento da depressão maior envolvem a aplicação de dois eletrodos-esponja no escalpo. Em geral, o eletrodo positivo é aplicado na região sobrejacente ao córtex pré-frontal dorsolateral esquerdo (região F3 do Sistema Internacional 10/20 para eletroencefalograma) e o eletrodo negativo é aplicado na região sobrejacente à área supra-orbital direita. Uma corrente elétrica direta de 1-2 mA é então aplicada entre os dois eletrodos por cerca 20 minutos, sendo as sessões de estimulação transcraniana por corrente direta realizadas diariamente durante uma a duas semanas. Estudos iniciais (incluindo um ensaio clínico randomizado, duplo-cego e controlado por placebo) demonstraram que a estimulação transcraniana por corrente direta é efetiva no tratamento da depressão maior não-complicada e que essa técnica, quando utilizada em pacientes deprimidos, está associada com melhoras na performance cognitiva (incluindo na memória de trabalho). Por fim, a estimulação transcraniana por corrente direta é segura e bem tolerada. CONCLUSÃO: Investigações recentes demonstram que a estimulação transcraniana por corrente direta é um importante método neuromodulatório que pode ser útil no tratamento de pacientes deprimidos. Contudo, novos estudos são necessários para esclarecer seu real papel no manejo dos transtornos depressivos.

Transcranial direct current stimulation as a therapeutic tool for the treatment of major depression: insights from past and recent clinical studies

PURPOSE OF REVIEW

Transcranial direct current stimulation (tDCS) is a noninvasive method of brain stimulation that has been increasingly tested for the treatment of neuropsychiatric disorders. It has useful characteristics, such as low cost, ease of use, reliable sham methodology, and relatively powerful effects on cortical excitability. Because of its potential to modulate cortical excitability noninvasively, tDCS has been tested for the treatment of depression for several decades. Therefore, we reviewed evidence on the use of tDCS for major depression examining evidence from past and recent tDCS studies. We also briefly compared tDCS with other techniques of neuromodulation, namely deep brain stimulation, vagal nerve stimulation, and transcranial magnetic stimulation; and suggest future directions for the use of tDCS in major depression.

RECENT FINDINGS

Results from past clinical trials testing direct current stimulation as a therapeutic tool had mixed methodology and showed heterogeneous results. Recent studies on tDCS and depression using novel approaches, such as different parameters of stimulation, have improved its neuromodulatory effect thus resulting in larger clinical effects. In fact, two recent small trials have shown that tDCS is associated with significant clinical gains.

SUMMARY

On the basis of these findings there is still not enough evidence to support tDCS as a therapeutic modality for depression. However, findings to date encourage further studies in this area that should explore novel parameters of stimulation. In fact, it appears that current methods of tDCS might not be fully optimized and, in fact, (1) individualized parameters of stimulation, (2) longer stimulation sessions, and (3) methods to focalize tDCS might be useful strategies to provide greater clinical benefits.

Using non-invasive brain stimulation to augment motor training-induced plasticity

Therapies for motor recovery after stroke or traumatic brain injury are still not satisfactory. To date the best approach seems to be the intensive physical therapy. However the results are limited and functional gains are often minimal. The goal of motor training is to minimize functional disability and optimize functional motor recovery. This is thought to be achieved by modulation of plastic changes in the brain. Therefore, adjunct interventions that can augment the response of the motor system to the behavioural training might be useful to enhance the therapy-induced recovery in neurological populations. In this context, noninvasive brain stimulation appears to be an interesting option as an add-on intervention to standard physical therapies. Two non-invasive methods of inducing electrical currents into the brain have proved to be promising for inducing long-lasting plastic changes in motor systems: transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). These techniques represent powerful methods for priming cortical excitability for a subsequent motor task, demand, or stimulation. Thus, their mutual use can optimize the plastic changes induced by motor practice, leading to more remarkable and outlasting clinical gains in rehabilitation. In this review we discuss how these techniques can enhance the effects of a behavioural intervention and the clinical evidence to date.

Transcranial magnetic stimulation, synaptic plasticity and network oscillations

Transcranial magnetic stimulation (TMS) has quickly progressed from a technical curiosity to a bona-fide tool for neurological research. The impetus has been due to the promising results obtained when using TMS to uncover neural processes in normal human subjects, as well as in the treatment of intractable neurological conditions, such as stroke, chronic depression and epilepsy. The basic principle of TMS is that most neuronal axons that fall within the volume of magnetic stimulation become electrically excited, trigger action potentials and release neurotransmitter into the postsynaptic neurons. What happens afterwards remains elusive, especially in the case of repeated stimulation. Here we discuss the likelihood that certain TMS protocols produce long-term changes in cortical synapses akin to long-term potentiation and long-term depression of synaptic transmission. Beyond the synaptic effects, TMS might have consequences on other neuronal processes, such as genetic and protein regulation, and circuit-level patterns, such as network oscillations. Furthermore, TMS might have non-neuronal effects, such as changes in blood flow, which are still poorly understood.

Facilitating skilled right hand motor function in older subjects by anodal polarization over the left primary motor cortex

Healthy ageing is accompanied by limitations in performance of activities of daily living and personal independence. Recent reports demonstrated improvements in motor function induced by noninvasive anodal direct current stimulation (tDCS) of the primary motor cortex (M1) in young healthy adults. Here we tested the hypothesis that a single session of anodal tDCS over left M1 could facilitate performance of right upper extremity tasks required for activities of daily living (Jebsen-Taylor hand function test, JTT) in older subjects relative to Sham in a double-blind cross-over study design. We found (a) significant improvement in JTT function with tDCS relative to Sham that outlasted the stimulation period by at least 30 min, (b) that the older the subjects the more prominent this improvement appeared and (c) that consistent with previous results in younger subjects, these effects were not accompanied by any overt undesired side effect. We conclude that anodal tDCS applied over M1 can facilitate performance of skilled hand functions required for activities of daily living in older subjects.

Transcranial magnetic stimulation in heterogeneous brain tissue: clinical impact on focality, reproducibility and true sham stimulation

BACKGROUND

Transcranial magnetic stimulation (TMS) is an attractive research and possibly therapeutic tool for non-invasive central nervous system stimulation. However, relatively little is known about the direction, magnitude and distribution of induced electric field and current flows in tissue, and optimal setup characteristics as well as appropriate sham stimulation conditions remain largely undetermined, hampering reproducibility.

METHODS

We reconstruct the conductive phenomena induced by TMS by implementing digitized coil geometry and realistic stimulator parameters and solving the electromagnetic problem over an MRI-based, realistic head model of 1mm resolution. Findings are validated by recording motor evoked potentials from the right abductor pollicis brevis muscle from healthy subjects stimulated in a stereotaxic framework.

RESULTS

Several commonly used sham stimulation configurations elicit conductive patterns which achieve up to 40% of the strength of real stimulation. Also, variations in coil position of the order of a 7 degrees tilt, which are expected to occur in non-stereotaxic stimulation, can alter the stimulation intensity by up to 25%.

CONCLUSIONS

In accordance with our findings, several clinical studies observe measurable effects during sham stimulation or no significant difference between sham and real stimulation, and the sensitivity of stimulation intensity to tiny coil rotations affords a partial explanation for the poor reproducibility and partial disagreements observed across clinical TMS studies. Knowledge of coil and stimulator specifications alone is hence not sufficient to control stimulation conditions, and a stereotaxic setup coupled with individually adjusted field solvers appear essential in performing reliable TMS studies.

Remote excitation of neuronal circuits using low-intensity, low-frequency ultrasound

Possessing the ability to noninvasively elicit brain circuit activity yields immense experimental and therapeutic power. Most currently employed neurostimulation methods rely on the somewhat invasive use of stimulating electrodes or photon-emitting devices. Due to its ability to noninvasively propagate through bone and other tissues in a focused manner, the implementation of ultrasound (US) represents a compelling alternative approach to current neuromodulation strategies. Here, we investigated the influence of low-intensity, low-frequency ultrasound (LILFU) on neuronal activity. By transmitting US waveforms through hippocampal slice cultures and ex vivo mouse brains, we determined LILFU is capable of remotely and noninvasively exciting neurons and network activity. Our results illustrate that LILFU can stimulate electrical activity in neurons by activating voltage-gated sodium channels, as well as voltage-gated calcium channels. The LILFU-induced changes in neuronal activity were sufficient to trigger SNARE-mediated exocytosis and synaptic transmission in hippocampal circuits. Because LILFU can stimulate electrical activity and calcium signaling in neurons as well as central synaptic transmission we conclude US provides a powerful tool for remotely modulating brain circuit activity.

Biophysical foundations underlying TMS: setting the stage for an effective use of neurostimulation in the cognitive neurosciences

Transcranial Magnetic Stimulation (TMS) induces electrical currents in the brain to stimulate neural tissue. This article reviews our present understanding of TMS methodology, focusing on its biophysical foundations. We concentrate on how the laws of electromagnetic induction apply to TMS; addressing issues such as the location, area (i.e., focality), depth, and mechanism of TMS. We also present a review of the present limitations and future potential of the technique.

Mapping causal interregional influences with concurrent TMS-fMRI

Transcranial magnetic stimulation (TMS) produces a direct causal effect on brain activity that can now be studied by new approaches that simultaneously combine TMS with neuroimaging methods, such as functional magnetic resonance imaging (fMRI). In this review we highlight recent concurrent TMS-fMRI studies that illustrate how this novel combined technique may provide unique insights into causal interactions among brain regions in humans. We show how fMRI can detect the spatial topography of local and remote TMS effects and how these may vary with psychological factors such as task-state. Concurrent TMS-fMRI may furthermore reveal how the brain adapts to so-called virtual lesions induced by TMS, and the distributed activity changes that may underlie the behavioural consequences often observed during cortical stimulation with TMS. We argue that combining TMS with neuroimaging techniques allows a further step in understanding the physiological underpinnings of TMS, as well as the neural correlated of TMS-evoked consequences on perception and behaviour. This can provide powerful new insights about causal interactions among brain regions in both health and disease that may ultimately lead to developing more efficient protocols for basic research and therapeutic TMS applications.

The continuous Wagon wheel illusion and the 'when' pathway of the right parietal lobe: a repetitive transcranial magnetic stimulation study

A continuous periodic motion stimulus can sometimes be perceived moving in the wrong direction. These illusory reversals have been taken as evidence that part of the motion perception system samples its inputs as a series of discrete snapshots -although other explanations of the phenomenon have been proposed, that rely on the spurious activation of low-level motion detectors in early visual areas. We have hypothesized that the right inferior parietal lobe ('when' pathway) plays a critical role in timing perceptual events relative to one another, and thus we examined the role of the right parietal lobe in the generation of this "continuous Wagon Wheel Illusion" (c-WWI). Consistent with our hypothesis, we found that the illusion was effectively weakened following disruption of right, but not left, parietal regions by low frequency repetitive transcranial magnetic stimulation (1 Hz, 10 min). These results were independent of whether the motion stimulus was shown in the left or the right visual field. Thus, the c-WWI appears to depend on higher-order attentional mechanisms that are supported by the 'when' pathway of the right parietal lobe.

Modulation of emotions associated with images of human pain using anodal transcranial direct current stimulation (tDCS)

Viewing images of other humans in pain elicits a variety of responses including distress, anxiety, and a sensation that is similar to pain. We aimed to evaluate whether transcranial direct current stimulation (tDCS) could be effective in modulating the emotional aspects of pain as to further explore mechanisms of tDCS in pain relief. Twenty-three healthy subjects rated images with respect to unpleasantness and discomfort/pain (baseline), and then received stimulation with tDCS under four different conditions of stimulation: anodal tDCS of the left primary motor cortex (M1), dorsolateral prefrontal cortex (DLPFC), occipital cortex (V1); and sham tDCS. The order of conditions was randomized and counterbalanced across subjects. During each stimulation session (after 3 min of stimulation), subjects were shown a new set of aversive images and were again asked to rate the images with respect to unpleasantness and discomfort/pain. The results showed that ratings of unpleasantness and discomfort/pain were significantly decreased during DLPFC tDCS only, as compared to baseline and sham tDCS. The other conditions of stimulation (M1 and V1 tDCS) did not result in any significant changes. These results support the notion that DLPFC is a critical area for the emotional processing of pain and also suggests that DLPFC may be a potential target of stimulation for alleviation of pain with a significant emotional-affective component. Our results also suggest that the mechanism of tDCS in modulating emotional pain involve pathways that are independent of those modulating the somatosensory perception of pain.

Consensus: Motor cortex plasticity protocols

Noninvasive transcranial stimulation is being increasingly used by clinicians and neuroscientists to alter deliberately the status of the human brain. Important applications are the induction of virtual lesions (for example, transient dysfunction) to identify the importance of the stimulated brain network for a certain sensorimotor or cognitive task, and the induction of changes in neuronal excitability, synaptic plasticity or behavioral function outlasting the stimulation, for example, for therapeutic purposes. The aim of this article is to review critically the properties of the different currently used stimulation protocols, including a focus on their particular strengths and weaknesses, to facilitate their appropriate and conscientious application.

Controversy: Does repetitive transcranial magnetic stimulation/ transcranial direct current stimulation show efficacy in treating tinnitus patients?

BACKGROUND

Tinnitus affects 10% of the population, its pathophysiology remains incompletely understood, and treatment is elusive. Functional imaging has demonstrated a relationship between the intensity of tinnitus and the degree of reorganization in the auditory cortex. Experimental studies have further shown that tinnitus is associated with synchronized hyperactivity in the auditory cortex. Therefore, targeted modulation of auditory cortex has been proposed as a new therapeutic approach for chronic tinnitus.

METHODS

Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive methods that can modulate cortical activity. These techniques have been applied in different ways in patients with chronic tinnitus. Single sessions of high-frequency rTMS over the temporal cortex have been successful in reducing the intensity of tinnitus during the time of stimulation and could be predictive for treatment outcome of chronic epidural stimulation using implanted electrodes.

RESULTS

Another approach that uses rTMS as a treatment for tinnitus is application of low-frequency rTMS in repeated sessions, to induce a lasting change of neuronal activity in the auditory cortex beyond the duration of stimulation. Beneficial effects of this treatment have been consistently demonstrated in several small controlled studies. However, results are characterized by high interindividual variability and only a moderate decrease of the tinnitus. The role of patient-related (for example, hearing loss, tinnitus duration, age) and stimulation-related (for example, stimulation site, stimulation protocols) factors still remains to be elucidated.

CONCLUSIONS

Even in this early stage of investigation, there is a convincing body of evidence that rTMS represents a promising tool for pathophysiological assessment and therapeutic management of tinnitus. Further development of this technique will depend on a more detailed understanding of the neurobiological effects mediating the benefit of TMS on tinnitus perception. Moreover clinical studies with larger sample sizes and longer follow-up periods are needed.

Baseline cortical excitability determines whether TMS disrupts or facilitates behavior

Transcranial magnetic stimulation (TMS) is increasingly used to modify brain activity noninvasively and to study brain-behavior relations. However, results can be variable and the conditions that affect the functional efficacy of TMS remain unclear. Here we show that on-line TMS can either facilitate or suppress perceptual functions depending on the baseline level of activity of the targeted brain region. When TMS was applied over the motion selective region V5/MT during a simple motion-detection task, subjects' motion-detection ability was impaired. Similarly, suppression of V5/MT activity using off-line 1 Hz repetitive TMS (rTMS) disrupted performance in a subsequent motion-detection task. However, paradoxically, on-line V5/MT TMS had a facilitatory effect on motion detection if V5/MT had been suppressed by off-line 1-Hz rTMS prior to the motion-detection task. These results demonstrate that TMS can have an unexpected facilitatory effect on behavior when the targeted neural population is in a suppressed state. Our findings provide further evidence for the view that the effects of TMS are modulated by the initial activation state of the targeted neural population.

Noninvasive brain stimulation for Parkinson's disease and dystonia

Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are promising noninvasive cortical stimulation methods for adjunctive treatment of movement disorders. They avoid surgical risks and provide theoretical advantages of specific neural circuit neuromodulation. Neuromodulatory effects depend on extrinsic stimulation factors (cortical target, frequency, intensity, duration, number of sessions), intrinsic patient factors (disease process, individual variability and symptoms, state of medication treatment), and outcome measures. Most studies to date have shown beneficial effects of rTMS or tDCS on clinical symptoms in Parkinson's disease (PD) and support the notion of spatial specificity to the effects on motor and nonmotor symptoms. Stimulation parameters have varied widely, however, and some studies are poorly controlled. Studies of rTMS or tDCS in dystonia have provided abundant data on physiology, but few on clinical effects. Multiple mechanisms likely contribute to the clinical effects of rTMS and tDCS in movement disorders, including normalization of cortical excitability, rebalancing of distributed neural network activity, and induction of dopamine release. It remains unclear how to individually adjust rTMS or tDCS factors for the most beneficial effects on symptoms of PD or dystonia. Nonetheless, the noninvasive nature, minimal side effects, positive effects in preliminary clinical studies, and increasing evidence for rational mechanisms make rTMS and tDCS attractive for ongoing investigation.

Transcranial magnetic stimulation and brain atrophy: a computer-based human brain model study

This paper is aimed at exploring the effect of cortical brain atrophy on the currents induced by transcranial magnetic stimulation (TMS). We compared the currents induced by various TMS conditions on several different MRI derived finite element head models of brain atrophy, incorporating both decreasing cortical volume and widened sulci. The current densities induced in the cortex were dependent upon the degree and type of cortical atrophy and were altered in magnitude, location, and orientation when compared to healthy head models. Predictive models of the degree of current density attenuation as a function of the scalp-to-cortex distance were analyzed, concluding that those which ignore the electromagnetic field-tissue interactions lead to inaccurate conclusions. Ultimately, the precise site and population of neural elements stimulated by TMS in an atrophic brain cannot be predicted based on healthy head models which ignore the effects of the altered cortex on the stimulating currents. Clinical applications of TMS should be carefully considered in light of these findings.

Transcranial magnetic stimulation in child neurology: current and future directions

Transcranial magnetic stimulation (TMS) is a method for focal brain stimulation based on the principle of electromagnetic induction, where small intracranial electric currents are generated by a powerful, rapidly changing extracranial magnetic field. Over the past 2 decades TMS has shown promise in the diagnosis, monitoring, and treatment of neurological and psychiatric disease in adults, but has been used on a more limited basis in children. We reviewed the literature to identify potential diagnostic and therapeutic applications of TMS in child neurology and also its safety in pediatrics. Although TMS has not been associated with any serious side effects in children and appears to be well tolerated, general safety guidelines should be established. The potential for applications of TMS in child neurology and psychiatry is significant. Given its excellent safety profile and possible therapeutic effect, this technique should develop as an important tool in pediatric neurology over the next decade.

Diminishing risk-taking behavior by modulating activity in the prefrontal cortex: a direct current stimulation study

Studies have shown increased risk taking in healthy individuals after low-frequency repetitive transcranial magnetic stimulation, known to transiently suppress cortical excitability, over the right dorsolateral prefrontal cortex (DLPFC). It appears, therefore, plausible that differential modulation of DLPFC activity, increasing the right while decreasing the left, might lead to decreased risk taking, which could hold clinical relevance as excessively risky decision making is observed in clinical populations leading to deleterious consequences. The goal of the present study was to investigate whether risk-taking behaviors could be decreased using concurrent anodal transcranial direct current stimulation (tDCS) of the right DLPFC, which allows upregulation of brain activity, with cathodal tDCS of the left DLPCF, which downregulates activity. Thirty-six healthy volunteers performed the risk task while they received either anodal over the right with cathodal over the left DLPFC, anodal over the left with cathodal over the right DLPFC, or sham stimulation. We hypothesized that right anodal/left cathodal would decrease risk-taking behavior compared with left anodal/right cathodal or sham stimulation. As predicted, during right anodal/left cathodal stimulation over the DLPFC, participants chose more often the safe prospect compared with the other groups. Moreover, these participants appeared to be insensitive to the reward associated with the prospects. These findings support the notion that the interhemispheric balance of activity across the DLPFCs is critical in decision-making behaviors. Most importantly, the observed suppression of risky behaviors suggests that populations with boundless risk-taking behaviors leading to negative real-life consequences, such as individuals with addiction, might benefit from such neuromodulation-based approaches.