Transcranial magnetic stimulation: a primer

[Transcranial magnetic stimulation (TMS) in basic and clinical neuroscience research]

INTRODUCTION

Non-invasive brain stimulation methods such as transcranial magnetic stimulation (TMS) are starting to be widely used to make causality-based inferences about brain-behavior interactions. Moreover, TMS-based clinical applications are under development to treat specific neurological or psychiatric conditions, such as depression, dystonia, pain, tinnitus and the sequels of stroke, among others.

BACKGROUND

TMS works by inducing non-invasively electric currents in localized cortical regions thus modulating their activity levels according to settings, such as frequency, number of pulses, train and regime duration and intertrain intervals. For instance, it is known for the motor cortex that low frequency or continuous patterns of TMS pulses tend to depress local activity whereas high frequency and discontinuous TMS patterns tend to enhance it. Additionally, local cortical effects of TMS can result in dramatic patterns in distant brain regions. These distant effects are mediated via anatomical connectivity in a magnitude that depends on the efficiency and sign of such connections.

PERSPECTIVES

An efficient use of TMS in both fields requires however, a deep understanding of its operational principles, its risks, its potential and limitations. In this article, we will briefly present the principles through which non-invasive brain stimulation methods, and in particular TMS, operate.

CONCLUSION

Readers will be provided with fundamental information needed to critically discuss TMS studies and design hypothesis-driven TMS applications for cognitive and clinical neuroscience research.

Observation-execution matching and action inhibition in human primary motor cortex during viewing of speech-related lip movements or listening to speech

One influential theory posits that language has evolved from gestural communication through observation-execution matching processes in the mirror neuron system (MNS). This theory predicts that observation of speech-related lip movements or even listening to speech would result in effector and task specific increase of the excitability of the corresponding motor representations in the primary motor cortex (M1), since actual movement execution is known be effector and task specific. In addition, effector and task specific inhibitory control mechanisms should be important to prevent overt motor activation during observation of speech-related lip movements or listening to speech. We tested these predictions by applying focal transcranial magnetic stimulation to the left M1 of 12 healthy right-handed volunteers and measuring motor evoked potentials (MEPs) and short-interval intracortical inhibition (SICI) in a lip muscle, the right orbicularis oris (OO), vs. a hand muscle, the right first dorsal interosseus (FDI). We found that MEP and SICI increased only in the OO but not in the FDI during viewing of speech-related lip movements or listening to speech. These changes were highly task specific because they were absent when lip movements non-related to speech were viewed. Finally, the increase in MEP amplitude in the OO correlated inversely with accuracy of speech perception, i.e. the MEP increase was directly related to task difficulty. The MEP findings support the notion that observation-execution matching is an operating process in the putative human MNS that might have been fundamental for evolution of language. Furthermore, the SICI findings provide evidence that inhibitory mechanisms are recruited to prevent unwanted overt motor activation during action observation.

Sensorimotor rhythm-based brain-computer interface training: the impact on motor cortical responsiveness

The main purpose of electroencephalography (EEG)-based brain-computer interface (BCI) technology is to provide an alternative channel to support communication and control when motor pathways are interrupted. Despite the considerable amount of research focused on the improvement of EEG signal detection and translation into output commands, little is known about how learning to operate a BCI device may affect brain plasticity. This study investigated if and how sensorimotor rhythm-based BCI training would induce persistent functional changes in motor cortex, as assessed with transcranial magnetic stimulation (TMS) and high-density EEG. Motor imagery (MI)-based BCI training in naïve participants led to a significant increase in motor cortical excitability, as revealed by post-training TMS mapping of the hand muscle's cortical representation; peak amplitude and volume of the motor evoked potentials recorded from the opponens pollicis muscle were significantly higher only in those subjects who develop a MI strategy based on imagination of hand grasping to successfully control a computer cursor. Furthermore, analysis of the functional brain networks constructed using a connectivity matrix between scalp electrodes revealed a significant decrease in the global efficiency index for the higher-beta frequency range (22-29 Hz), indicating that the brain network changes its topology with practice of hand grasping MI. Our findings build the neurophysiological basis for the use of non-invasive BCI technology for monitoring and guidance of motor imagery-dependent brain plasticity and thus may render BCI a viable tool for post-stroke rehabilitation.

Mechanisms of magnetic stimulation of central nervous system neurons

Transcranial magnetic stimulation (TMS) is a stimulation method in which a magnetic coil generates a magnetic field in an area of interest in the brain. This magnetic field induces an electric field that modulates neuronal activity. The spatial distribution of the induced electric field is determined by the geometry and location of the coil relative to the brain. Although TMS has been used for several decades, the biophysical basis underlying the stimulation of neurons in the central nervous system (CNS) is still unknown. To address this problem we developed a numerical scheme enabling us to combine realistic magnetic stimulation (MS) with compartmental modeling of neurons with arbitrary morphology. The induced electric field for each location in space was combined with standard compartmental modeling software to calculate the membrane current generated by the electromagnetic field for each segment of the neuron. In agreement with previous studies, the simulations suggested that peripheral axons were excited by the spatial gradients of the induced electric field. In both peripheral and central neurons, MS amplitude required for action potential generation was inversely proportional to the square of the diameter of the stimulated compartment. Due to the importance of the fiber's diameter, magnetic stimulation of CNS neurons depolarized the soma followed by initiation of an action potential in the initial segment of the axon. Passive dendrites affect this process primarily as current sinks, not sources. The simulations predict that neurons with low current threshold are more susceptible to magnetic stimulation. Moreover, they suggest that MS does not directly trigger dendritic regenerative mechanisms. These insights into the mechanism of MS may be relevant for the design of multi-intensity TMS protocols, may facilitate the construction of magnetic stimulators, and may aid the interpretation of results of TMS of the CNS.

Transcranial magnetic stimulation (TMS) is a widely applied tool for probing cognitive function in humans and is one of the best tools for clinical treatments and interfering with cognitive tasks. Surprisingly, while TMS has been commercially available for decades, the cellular mechanisms underlying magnetic stimulation remain unclear. Here we investigate these mechanisms using compartmental modeling. We generated a numerical scheme allowing simulation of the physiological response to magnetic stimulation of neurons with arbitrary morphologies and active properties. Computational experiments using this scheme suggested that TMS affects neurons in the central nervous system (CNS) primarily by somatic stimulation. Since magnetic stimulation appears to cause somatic depolarization, its effects are highly correlated with the neuron's current threshold. Our simulations therefore predict that subpopulations of CNS neurons with different firing thresholds will respond differently to magnetic stimulation. For example, low-intensity TMS may be used to stimulate low-threshold cortical inhibitory interneurons. At higher intensities we predict that both inhibitory and excitatory neurons are activated. These predictions may be tested at the cellular level and may impact cognitive experiments in humans. Furthermore, our simulations may be used to design TMS coils, devices and protocols.

TMS-induced blinking assessed with high-speed video: optical disruption of visual perception

It is known that TMS can induce blinking, but it is unknown to what extent and at what time TMS-induced blinking can cover the pupil. We applied single-pulse TMS with a leftward and rightward monophasic current through a round coil over the occipital pole in 8 healthy subjects, using high-speed video to monitor left or right eye with a spatial resolution of 0.1 mm and a temporal resolution of 2 ms. We plotted eyelid position relative to upper and lower pupil borders as a function of time after TMS for each subject and current direction. We found 2 blinks in every subject, an isolated late blink with one current direction and a superimposed early and late blink with the other current direction, in accordance with our previously reported association between a leftward and rightward lower coil rim current and an early blink in right and left eye, respectively. Blink extent varied, but 4 subjects showed total pupil covering with both current directions. Blink timing varied, but pupil covering was initiated as early as 32 ms after TMS and pupil uncovering was completed as late as 200 ms after TMS. We found no saccades. We conclude that TMS can cause an important optical disruption of visual perception.

Assessment and modulation of neural plasticity in rehabilitation with transcranial magnetic stimulation

Despite intensive efforts to improve outcomes after acquired brain injury, functional recovery is often limited. One reason for this limitation is the challenge in assessing and guiding plasticity after brain injury. In this context, transcranial magnetic stimulation (TMS), a noninvasive tool of brain stimulation, could play a major role. TMS has been shown to be a reliable tool for measuring plastic changes in the motor cortex associated with interventions in the motor system, such as motor training and motor cortex stimulation. In addition, as illustrated by the experience in promoting recovery from stroke, TMS is a promising therapeutic tool to minimize motor, speech, cognitive, and mood deficits. In this review, we will focus on stroke to discuss how TMS can provide insights into the mechanisms of neurologic recovery and how it can be used for measurement and modulation of plasticity after an acquired brain insult.

Current trends in stroke rehabilitation. A review with focus on brain plasticity

Current understanding of brain plasticity has lead to new approaches in ischemic stroke rehabilitation. Stroke units that combine good medical and nursing care with task-oriented intense training in an environment that provides confidence, stimulation and motivation significantly improve outcome. Repetitive trans-cranial magnetic stimulation (rTMS), and trans-cranial direct current stimulation (tDCS) are applied in rehabilitation of motor function. The long-term effect, optimal way of stimulation and possibly efficacy in cognitive rehabilitation need evaluation. Methods based on multisensory integration of motor, cognitive, and perceptual processes including action observation, mental training, and virtual reality are being tested. Different approaches of intensive aphasia training are described. Recent data on intensive melodic intonation therapy indicate that even patients with very severe non-fluent aphasia can regain speech through homotopic white matter tract plasticity. Music therapy is applied in motor and cognitive rehabilitation. To avoid the confounding effect of spontaneous improvement, most trials are preformed ≥3 months post stroke. Randomized controlled trials starting earlier after strokes are needed. More attention should be given to stroke heterogeneity, cognitive rehabilitation, and social adjustment and to genetic differences, including the role of BDNF polymorphism in brain plasticity.

Transcranial magnetic stimulation at the interface with other techniques: a powerful tool for studying the human cortex

Transcranial magnetic stimulation (TMS) has developed into a very powerful tool in the hands of basic and clinical neuroscientists alike to study function and dysfunction of the human brain noninvasively and painlessly. However, as a stand-alone technique, the potential of TMS to gain knowledge is relatively limited. This potential can be strongly enhanced by combining TMS with simultaneous measurements in other electrophysiological (EEG) or imaging modalities (PET, fMRI, NIRS, MRS) or by combining TMS with exposure to neuroactive drugs (pharmaco-TMS). This review provides an up-to-date synopsis of these combined approaches and highlights important examples that have advanced our understanding of how TMS interacts with neuronal networks in the human brain.

Non-invasive brain stimulation: enhancing motor and cognitive functions in healthy old subjects

Healthy aging is accompanied by changes in cognitive and motor functions that result in impairment of activities of daily living. This process involves a number of modifications in the brain and is associated with metabolic, structural, and physiological changes; some of these serving as adaptive responses to the functional declines. Up to date there are no universally accepted strategies to ameliorate declining functions in this population. An essential basis to develop such strategies is a better understanding of neuroplastic changes during healthy aging. In this context, non-invasive brain stimulation techniques, such as transcranial direct current or transcranial magnetic stimulation, provide an attractive option to modulate cortical neuronal assemblies, even with subsequent changes in neuroplasticity. Thus, in the present review we discuss the use of these techniques as a tool to study underlying cortical mechanisms during healthy aging and as an interventional strategy to enhance declining functions and learning abilities in aged subjects.

Clinical relevance and neurophysiological correlates of spasticity in cerebrotendinous xanthomatosis

Cerebrotendinous xanthomatosis (CTX) is a rare neurometabolic disease due to defective activity of sterol 27-hydroxylase, with plasma and tissue cholestanol storage. Clinical phenotype is characterized by both systemic manifestations and neurological signs. Therapy with chenodeoxycholic acid (CDCA) suppresses abnormal bile acid synthesis. The purpose of the study was to assess the frequency and clinical relevance of spasticity in the CTX phenotype and to study the usefulness of transcranial magnetic stimulation (TMS) in detecting corticospinal tract damage and monitoring the effects of replacement therapy. Twenty-four CTX patients underwent clinical evaluation including general disability scores, pyramidal and cerebellar function scales, assessment of serum cholestanol and TMS. Nine patients who started CDCA therapy at baseline received clinical and neurophysiological follow up. All patients showed signs of pyramidal damage which were relevant for clinical disability in 18 out of 24 cases (75%), resulting in spastic paraparesis. TMS revealed corticospinal alterations even in subjects with mild clinical signs of corticospinal tract involvement. After CDCA treatment, serum cholestanol decreased to normal concentrations in all patients. Clinical picture was unchanged in seven out of nine cases; in two others pyramidal signs disappeared. A reduction in abnormal neurophysiological parameters was found. Spastic paraparesis is the most frequent and relevant neurological feature in CTX patients. Replacement treatment with CDCA can prevent the progression of pyramidal damage, especially if started early in the course of the disease. TMS represents a sensitive indicator of corticospinal tract dysfunction and subclinical improvements in pyramidal function after CDCA therapy.

Modulation of corticomotor excitability by an I-wave intervention delivered during low-level voluntary contraction

Transcranial magnetic stimulation (TMS) interventions that modulate cortical plasticity may achieve a more functional benefit if combined with neuro-rehabilitation therapies. With a TMS protocol targeting I-wave dynamics, it is possible to deliver stimuli while a subject performs a motor task, and this may more effectively target functional networks related to the task. However, the efficacy of this intervention during a simple task such as a low-level voluntary contraction is not known. We delivered paired-pulse TMS at an inter-pulse interval (IPI) of 1.5 ms for 15 min while subjects performed a 10 ± 2.5% voluntary contraction of the first dorsal interosseous (FDI) muscle and made motor evoked potential (MEP) amplitude and short-interval intracortical facilitation (SICF) curve measurements. Pre-intervention SICF curves showed only a single peak at 1.3-1.5 ms IPI. During the intervention, MEP amplitude steadily increased (P < 0.001) to 137 ± 13% of its initial value. After the intervention, SICF curves were increased in amplitude (P < 0.001) and later peaks emerged at 2.8 and 4.3 ms IPIs. A control experiment, replacing paired-pulse stimulation with single-pulse stimulation showed no effect on MEP amplitude (P = 0.951). We conclude that the I-wave intervention can be administered concurrently with a simple motor task and that it acts by increasing trans-synaptic efficacy across a number of I-waves. The ability to perform a motor task simultaneously with a TMS intervention could confer a degree of specificity to the induced excitability changes and may be beneficial for functional neuro-rehabilitation programs built around motor learning and retraining.

Using repetitive transcranial magnetic stimulation to study the underlying neural mechanisms of human motor learning and memory

In the last two decades, there has been a rapid development in the research of the physiological brain mechanisms underlying human motor learning and memory. While conventional memory research performed on animal models uses intracellular recordings, microfusion of protein inhibitors to specific brain areas and direct induction of focal brain lesions, human research has so far utilized predominantly behavioural approaches and indirect measurements of neural activity. Repetitive transcranial magnetic stimulation (rTMS), a safe non-invasive brain stimulation technique, enables the study of the functional role of specific cortical areas by evaluating the behavioural consequences of selective modulation of activity (excitation or inhibition) on memory generation and consolidation, contributing to the understanding of the neural substrates of motor learning. Depending on the parameters of stimulation, rTMS can also facilitate learning processes, presumably through purposeful modulation of excitability in specific brain regions. rTMS has also been used to gain valuable knowledge regarding the timeline of motor memory formation, from initial encoding to stabilization and long-term retention. In this review, we summarize insights gained using rTMS on the physiological and neural mechanisms of human motor learning and memory. We conclude by suggesting possible future research directions, some with direct clinical implications.

Mini-coil for magnetic stimulation in the behaving primate

Transcranial magnetic stimulation (TMS) is rapidly becoming a leading method in both cognitive neuroscience and clinical neurology. However, the cellular and network level effects of stimulation are still unclear and their study relies heavily on indirect physiological measurements in humans. Direct electrophysiological studies of the effect of magnetic stimulation on neuronal activity in behaving animals are severely limited by both the size of the stimulating coils, which affect large regions of the animal brain, and the large artifacts generated on the recording electrodes. We present a novel mini-coil which is specifically aimed at studying the neurophysiological mechanism of magnetic stimulation in behaving primates. The mini-coil fits into a chronic recording chamber and provides focal activation of brain areas while enabling simultaneous extracellular multi-electrode recordings. We present a comparison of this coil to a commercial coil based on the theoretical and recorded magnetic fields and induced electric fields they generate. Subsequently, we present the signal recorded in the behaving primate during stimulation and demonstrate the ability to extract the spike trains of multiple single units from each of the electrodes with minimal periods affected by the stimulus artifact (median period <2.5 ms). The directly recorded effect of the magnetic stimulation on cortical neurons is in line with peripheral recordings obtained in humans. This novel mini-coil is a key part of the infrastructure for studying the neurophysiological basis of magnetic stimulation, thereby enabling the development and testing of better magnetic stimulation tools and protocols for both neuroscientists and clinicians.

Effects of olfactory and gustatory stimuli on neural excitability for swallowing

This project evaluated the effects of olfactory and gustatory stimuli on the amplitude and latency of motor-evoked potentials (MEPs) from the submental muscles when evoked by transcranial magnetic stimulation (TMS). Sixteen healthy volunteers (8 males; age range 19-43) participated in the study. Lemon concentrate at 100% and diluted in water to 25% were presented separately as odor and tastant stimuli. Tap water was used as control. 15 trials of TMS-evoked MEPs triggered by volitional contraction of the submental muscles and volitional swallowing were measured at baseline, during control condition, during stimulus presentation, and immediately, 30-, 60-, and 90-min poststimulation for each of the four stimulus presentations. Experiments were repeated using the combined odor and tastant concentrations that most influenced the MEP independently. Differences in MEP amplitude measured during swallowing were seen at 30-, 60-, and 90-min poststimulation for simultaneous olfactory and gustatory stimulation as opposed to no differences seen at any point for stimuli presented separately. This study has shown that combined odor and tastant stimulation (i.e., flavor) can increase MEP amplitude during swallowing and that this enhancement of MEP can persist for at least 90min following stimulation. As increased MEP amplitude has been associated with improved swallowing performance, a follow-up study is underway to determine the biomechanical changes produced by altered MEPs to facilitate translation of these data to clinical dysphagia management.

Neurophysiology of dystonia: The role of inhibition

The pathophysiology of dystonia has been best studied in patients with focal hand dystonia. A loss of inhibitory function has been demonstrated at spinal, brainstem and cortical levels. Many cortical circuits seem to be involved. One consequence of the loss of inhibition is a failure of surround inhibition, and this appears to directly lead to overflow and unwanted muscle spasms. There are mild sensory abnormalities and deficits in sensorimotor integration; these also might be explained by a loss of inhibition. Increasing inhibition may be therapeutic. A possible hypothesis is that there is a genetic loss of inhibitory interneurons in dystonia and that this deficit is a substrate on which other factors can act to produce dystonia. This article is part of a Special Issue entitled "Advances in dystonia".

Long-Term Effects on Cortical Excitability and Motor Recovery Induced by Repeated Muscle Vibration in Chronic Stroke Patients

Background. Muscle vibration modifies corticomotor excitability in healthy subjects and reduces muscle tonus in stroke patients. Objective. This study examined whether repeated muscle vibration (rMV) applied over the flexor carpi radialis (FCR) and biceps brachii (BB) can induce long-lasting changes, using transcranial magnetic stimulation (TMS), in patients with chronic stroke. Methods. Thirty hemiparetic patients who offered at least minimal wrist and elbow isometric voluntary contractions were randomly assigned to either an experimental group, which received rMV in addition to physiotherapy (rMV + PT), or a control group that underwent PT alone. The following parameters of the FCR, BB, and extensor digitorum communis (EDC) were measured through TMS before, and 1 hour, 1 week, and 2 weeks after the end of intervention: resting motor threshold (RMT), map area, map volume, short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF). Muscle tonus and motor function were assessed on the same day as TMS. Results. Pre–post analysis revealed a reduction in RMT and an increase in motor map areas occurred in the vibrated muscles only in the rMV + PT group, with an increase in map volumes of all muscles. Moreover, SICI increased in the flexors and decreased in the extensor. These neurophysiological changes lasted for at least 2 weeks after the end of rMV + PT and paralleled the reduction in spasticity and increase in motor function. A significant correlation was found between the degree of spasticity and the amount of intracortical inhibition. Conclusion. rMV with PT may be used as a nonpharmacological intervention in the neurorehabilitation of mild to moderate hemiparesis.

The effects of electrical microstimulation on cortical signal propagation

Electrical stimulation has been used in animals and humans to study potential causal links between neural activity and specific cognitive functions. Recently, it has found increasing use in electrotherapy and neural prostheses. However, the manner in which electrical stimulation-elicited signals propagate in brain tissues remains unclear. We used combined electrostimulation, neurophysiology, microinjection and functional magnetic resonance imaging (fMRI) to study the cortical activity patterns elicited during stimulation of cortical afferents in monkeys. We found that stimulation of a site in the lateral geniculate nucleus (LGN) increased the fMRI signal in the regions of primary visual cortex (V1) that received input from that site, but suppressed it in the retinotopically matched regions of extrastriate cortex. Consistent with previous observations, intracranial recordings indicated that a short excitatory response occurring immediately after a stimulation pulse was followed by a long-lasting inhibition. Following microinjections of GABA antagonists in V1, LGN stimulation induced positive fMRI signals in all of the cortical areas. Taken together, our findings suggest that electrical stimulation disrupts cortico-cortical signal propagation by silencing the output of any neocortical area whose afferents are electrically stimulated.

Socially explosive minds: the triple imbalance hypothesis of reactive aggression

The psychobiological basis of reactive aggression, a condition characterized by uncontrolled outbursts of socially violent behavior, is unclear. Nonetheless, several theoretical models have been proposed that may have complementary views about the psychobiological mechanisms involved. In this review, we attempt to unite these models and theorize further on the basis of recent data from psychological and neuroscientific research to propose a comprehensive neuro-evolutionary framework: The Triple Imbalance Hypothesis (TIH) of reactive aggression. According to this model, reactive aggression is essentially subcortically motivated by an imbalance in the levels of the steroid hormones cortisol and testosterone (Subcortical Imbalance Hypothesis). This imbalance not only sets a primal predisposition for social aggression, but also down-regulates cortical-subcortical communication (Cortical-Subcortical Imbalance Hypothesis), hence diminishing control by cortical regions that regulate socially aggressive inclinations. However, these bottom-up hormonally mediated imbalances can drive both instrumental and reactive social aggression. The TIH suggests that reactive aggression is differentiated from proactive aggression by low brain serotonergic function and that reactive aggression is associated with left-sided frontal brain asymmetry (Cortical Imbalance Hypothesis), especially observed when the individual is socially threatened or provoked. This triple biobehavioral imbalance mirrors an evolutionary relapse into violently aggressive motivational drives that are adaptive among many reptilian and mammalian species, but may have become socially maladaptive in modern humans.

Enhanced human brain associative plasticity in Costello syndrome

Costello syndrome (CS) is a rare multiple congenital anomaly disorder which is caused by germline mutations in the v-Ha-ras Harvey rat sarcoma viral oncogene homologue (HRAS) proto-oncogene. Experimental data suggest perturbing effects of the mutated protein on the functional and structural organization of networks of cerebral cortex and on the activity-dependent strengthening of synaptic transmission known as long term potentiation (LTP). In five patients with molecularly proven diagnosis of CS and in a group of 13 age-matched control subjects we investigated activity-dependent synaptic plasticity. To this end, we used a paired associative stimulation (PAS) protocol, in which left ulnar nerve stimuli were followed by transcranial magnetic stimulation (TMS) pulses to right cortical hand area, and recorded motor evoked potentials (MEPs) by single pulse TMS from left first dorsal interosseus (FDI) muscle before and after PAS. In 4 out of 5 CS patients and in a subgroup of nine control subjects we also evaluated the time course and the topographical specificity of PAS after-effects. In these two subgroups, MEPs were measured before, immediately after and 30 min after PAS in the left FDI and left abductor pollicis brevis (APB). While the PAS protocol led to a 65% increase of the FDI MEP amplitude in controls, the LTP-like phenomenon was significantly more pronounced in CS patients, with motor responses increased by 230%. In addition, CS patients showed a similar MEP increase in both muscles while control subjects showed a slight increase in APB and only immediately after PAS. We hypothesize that the extremely enhanced PAS after-effects could be due to the influence of HRAS activity on the susceptibility of synapses to undergo LTP.

HF-rTMS treatment decreases psychomotor retardation in medication-resistant melancholic depression

Repetitive Transcranial Magnetic Stimulation (rTMS) applied to the left dorsolateral prefrontal cortex (DLPFC) might be a promising treatment strategy for depression. As one of the key features of melancholic depression is disturbances in psychomotor activity, we wanted to evaluate whether HF-rTMS treatment could influence psychomotor symptoms. Twenty antidepressant-free unipolar melancholic depressed patients, all at least stage III medication-resistant, were studied. All were treated with 10 sessions of High-Frequency (HF)-rTMS applied to the left dorsolateral prefrontal cortex (DLPFC) under MRI guidance. Forty percent of the patients showed a reduction of at least 50% on their initial 17-item Hamilton Depression Rating Score (HDRS) scale and were defined as clinical responders. Regardless of clinical outcome HF-rTMS treatment resulted in significant decreases on the Depressive Retardation Rating Scale (DRRS) scores. Although this was an open study in a relatively small sample, our results suggest that HF-rTMS might act on the 'psychomotor' level and these findings could add some further information as to why this kind of treatment can be beneficial for severely depressed patients of the melancholic subtype.

I. The little explored efficacy of magnetic fields in cancer treatment and postulation of the mechanism of action

There are many reports of enhanced transcription and replication in different cell culture systems exposed to electromagnetic fields, and reports of cytoreduction (necrosis and apoptosis) in tumors transplanted into animals exposed to similar, often much stronger electromagnetic fields, but where heating is negligible. Although the mechanism of apoptosis has not been characterized, one major candidate for the initiation of such a process is the production of numerous breaks in DNA, and the overwhelming of DNA repair processes, leading to the initiation of the apoptotic process. In this article, we concentrate on the potential of strong magnetic fields to play a role in cancer treatment.

The role of the dorsolateral prefrontal cortex in the inhibition of stereotyped responses

Stereotyped behaviors should be inhibited under some circumstances in order to encourage appropriate behavior. Psychiatrists have used the modified rock-paper-scissors (RPS) task to examine the inhibition of stereotyped behavior. When subjects are required to lose in response to a gesture, it is difficult for them to lose, and they have a tendency to win involuntarily. It is thought that the win response is the stereotyped response in the RPS task, and the difficulty in making positive attempts to lose is due to the requirement for inhibition of the stereotyped response. In this study, we investigated the brain regions related to inhibition of the stereotyped response using functional magnetic resonance imaging (fMRI). Subjects were assigned to one of two groups: the "win group" or the "lose group." The lose group showed higher activation of the left dorsolateral prefrontal cortex (DLFPC) when compared to the win group. We also delivered transcranial magnetic stimulation (TMS) while the subjects performed the modified RPS task to investigate whether the left DLPFC (middle frontal gyrus, Brodmann area, BA 9) was directly involved in the inhibition of the stereotyped response. When TMS was delivered before onset of the visual stimulus, the subjects displayed increased response errors. In particular, the subjects had a tendency to win erroneously in a lose condition even though they were required to lose. These results indicate involvement of the left DLPFC in inhibition of the stereotyped responses, which suggests that this region is associated with inhibition of the preparatory setting for stereotyped responses rather than inhibition of ongoing processing to produce a stereotyped response.

Control of wrist position and muscle relaxation by shifting spatial frames of reference for motoneuronal recruitment: possible involvement of corticospinal pathways

It has previously been established that muscles become active in response to deviations from a threshold (referent) position of the body or its segments, and that intentional motor actions result from central shifts in the referent position. We tested the hypothesis that corticospinal pathways are involved in threshold position control during intentional changes in the wrist position in humans. Subjects moved the wrist from an initial extended to a final flexed position (and vice versa). Passive wrist muscle forces were compensated with a torque motor such that wrist muscle activity was equalized at the two positions. It appeared that motoneuronal excitability tested by brief muscle stretches was also similar at these positions. Responses to mechanical perturbations before and after movement showed that the wrist threshold position was reset when voluntary changes in the joint angle were made. Although the excitability of motoneurons was similar at the two positions, the same transcranial magnetic stimulus (TMS) elicited a wrist extensor jerk in the extension position and a flexor jerk in the flexion position. Extensor motor-evoked potentials (MEPs) elicited by TMS at the wrist extension position were substantially bigger compared to those at the flexion position and vice versa for flexor MEPs. MEPs were substantially reduced when subjects fully relaxed wrist muscles and the wrist was held passively in each position. Results suggest that the corticospinal pathway, possibly with other descending pathways, participates in threshold position control, a process that pre-determines the spatial frame of reference in which the neuromuscular periphery is constrained to work. This control strategy would underlie not only intentional changes in the joint position, but also muscle relaxation. The notion that the motor cortex may control motor actions by shifting spatial frames of reference opens a new avenue in the analysis and understanding of brain function.

Novel and direct access to the human locomotor spinal circuitry

The degree of automaticity of locomotion in primates compared with other mammals remains unclear. Here, we examine the possibility for activation of the spinal locomotor circuitry in noninjured humans by spinal electromagnetic stimulation (SEMS). SEMS (3 Hz and 1.3-1.82 tesla) at the T11-T12 vertebrae induced involuntary bilateral locomotor-like movements in the legs of individuals placed in a gravity-neutral position. The formation of locomotor-like activity during SEMS started with a latency of 0.68 +/- 0.1 s after delivering the first stimulus, unlike continuous vibration of muscles, which requires several seconds. The first EMG burst in response to SEMS was observed most often in a proximal flexor muscle. We speculate that SEMS directly activates the circuitry intrinsic to the spinal cord, as suggested by the immediate response and the electrophysiological observations demonstrating an absence of strictly time-linked responses within the EMG burst associated with individual stimuli during SEMS. SEMS in the presence of vibration of the leg muscles was more effective in facilitating locomotor-like activity than SEMS alone. The present results suggest that SEMS could be an effective noninvasive clinical tool to determine the potential of an individual to recover locomotion after a spinal cord injury, as well as being an effective rehabilitation tool itself.

Effect of tDCS with an extracephalic reference electrode on cardio-respiratory and autonomic functions

Background

Transcranial direct current stimulation (tDCS) is used in human physiological studies and for therapeutic trials in patients with abnormalities of cortical excitability. Its safety profile places tDCS in the pole-position for translating in real-world therapeutic application. However, an episode of transient respiratory depression in a subject receiving tDCS with an extracephalic electrode led to the suggestion that such an electrode montage could modulate the brainstem autonomic centres.

We investigated whether tDCS applied over the midline frontal cortex in 30 healthy volunteers (sham n = 10, cathodal n = 10, anodal n = 10) with an extracephalic reference electrode would modulate brainstem activity as reflected by the monitoring and stringent analysis of vital parameters: heart rate (variability), respiratory rate, blood pressure and sympatho-vagal balance.

We reasoned that this study could lead to two opposite but equally interesting outcomes: 1) If tDCS with an extracephalic electrode modulated vital parameters, it could be used as a new tool to explore the autonomic nervous system and, even, to modulate its activity for therapeutic purposes. 2) On the opposite, if applying tDCS with an extracephalic electrode had no effect, it could thus be used safely in healthy human subjects. This outcome would significantly impact the field of non-invasive brain stimulation with tDCS. Indeed, on the one hand, using an extracephalic electrode as a genuine neutral reference (as opposed to the classical "bi-cephalic" tDCS montages which deliver bi-polar stimulation of the brain) would help to comfort the conclusions of several modern studies regarding the spatial location and polarity of tDCS. On the other hand, using an extracephalic reference electrode may impact differently on a given cortical target due to the change of direct current flow direction; this may enlarge the potential interventions with tDCS.

Results

Whereas the respiratory frequency decreased mildly over time and the blood pressure increased steadily, there was no differential impact of real (anodal or cathodal) versus sham tDCS. The heart rate remained stable during the monitoring period. The parameters reflecting the sympathovagal balance suggested a progressive shift over time favouring the sympathetic tone, again without differential impact of real versus sham tDCS.

Conclusions

Applying tDCS with an extracephalic reference electrode in healthy volunteers did not significantly modulate the activity of the brainstem autonomic centres. Therefore, using an extracephalic reference electrode for tDCS appears safe in healthy volunteers, at least under similar experimental conditions.

Studying the role of human parietal cortex in visuospatial attention with concurrent TMS-fMRI

Combining transcranial magnetic stimulation (TMS) with concurrent functional magnetic resonance imaging (fMRI) allows study of how local brain stimulation may causally affect activity in remote brain regions. Here, we applied bursts of high- or low-intensity TMS over right posterior parietal cortex, during a task requiring sustained covert visuospatial attention to either the left or right hemifield, or in a neutral control condition, while recording blood oxygenation-level–dependent signal with a posterior MR surface coil. As expected, the active attention conditions activated components of the well-described “attention network,” as compared with the neutral baseline. Also as expected, when comparing left minus right attention, or vice versa, contralateral occipital visual cortex was activated. The critical new finding was that the impact of high- minus low-intensity parietal TMS upon these visual regions depended on the currently attended side. High- minus low-intensity parietal TMS increased the difference between contralateral versus ipsilateral attention in right extrastriate visual cortex. A related albeit less pronounced pattern was found for left extrastriate visual cortex. Our results confirm that right human parietal cortex can exert attention-dependent influences on occipital visual cortex and provide a proof of concept for the use of concurrent TMS–fMRI in studying how remote influences can vary in a purely top–down manner with attentional demands.

Mechanisms and Dynamics of Cortical Motor Inhibition in the Stop-signal Paradigm: A TMS Study

The ability to stop ongoing motor responses in a split-second is a vital element of human cognitive control and flexibility that relies in large part on prefrontal cortex. We used the stop-signal paradigm to elucidate the engagement of primary motor cortex (M1) in inhibiting an ongoing voluntary motor response. The stop-signal paradigm taps the ability to flexibly countermand ongoing voluntary behavior upon presentation of a stop signal. We applied single-pulse TMS to M1 at several intervals following the stop signal to track the time course of excitability of the motor system related to generating and stopping a manual response. Electromyography recorded from the flexor pollicis brevis allowed quantification of the excitability of the corticospinal tract and the involvement of intracortical GABABergic circuits within M1, indexed respectively by the amplitude of the motor-evoked potential and the duration of the late part of the cortical silent period (SP). The results extend our knowledge of the neural basis of inhibitory control in three ways. First, the results revealed a dynamic interplay between response activation and stopping processes at M1 level during stop-signal inhibition of an ongoing response. Second, increased excitability of inhibitory interneurons that drives SP prolongation was evident as early as 134 msec following the instruction to stop. Third, this pattern was followed by a stop-related reduction of corticospinal excitability implemented around 180 after the stop signal. These findings point to the recruitment of GABABergic intracortical inhibitory circuits within M1 in stop-signal inhibition and support the notion of stopping as an active act of control.

Experience, cortical remapping, and recovery in brain disease

Recovery of motor function in brain and spinal cord disorders is an area of active research that seeks to maximize improvement after an episode of neuronal death or dysfunction. Recovery likely results from changes in structure and function of undamaged neurons, and this plasticity is a target for rehabilitative strategies. Sensory and motor function are mapped onto brain regions somatotopically, and these maps have been demonstrated to change in response to experience, particularly in development, but also in adults after injury. The map concept, while appealing, is limited, as the fine structure of the motor representation is not well-ordered somatotopically. But after stroke, the spared areas of the main cortical map for movement appear to participate in representing affected body parts, expanding representation in an experience-dependent manner. This occurs in both animal models and human clinical trials, although one must be cautious in comparing the results of invasive electrophysiological techniques with non-invasive ones such as transcranial magnetic stimulation. Developmental brain disorders, such as cerebral palsy, and embryonic abnormalities, such as dysmelia, demonstrate the potential of the human brain to remap the motor system. Future therapies may be able to use that potential to maximize recovery.

The noninvasive dissection of the human visual cortex: using FMRI and TMS to study the organization of the visual brain

The development of brain imaging techniques, such as fMRI, has given modern neuroscientists unparalleled access to the inner workings of the living human brain. Visual processing in particular has proven to be particularly amenable to study with fMRI. Studies using this technique have revealed the existence of multiple representations of visual space with differing functional roles across many cortical locations. Yet, although fMRI provides an excellent means by which we can localize and map different areas across the visual brain, it is less well suited to providing information as to whether activation within a particular cortical region is directly related to perception or behavior. These kinds of causal links can be made, however, when fMRI is combined with transcranial magnetic stimulation (TMS). TMS is a noninvasive technique that can bring about localized, transient disruption of cortical function and can induce functional impairments in the performance of specific tasks. When guided by the detailed localizing and mapping capabilities of fMRI, TMS can be used as a means by which the functional roles of different visual areas can be investigated. This review highlights recent insights that the techniques of fMRI and TMS have given us with regard to the function and contributions of the many different visual areas to human visual perception.

Identifying phronotypes in psychiatry

Refinements in the methods of diagnosis for psychiatric disorders are critically needed. These new methods should be based on objectively measured brain characteristics that provide clinically useful information. Studying the brain with respect to psychiatric disorders, however, faces numerous challenges. Utilizing techniques learned in other areas of medicine to deal with symptoms that lead to complex disorders can provide insight into improving diagnostic models in psychiatry. Specifically, many areas of medicine use objective measures of an organ's function or characteristic to guide clinical management of particular subjective complaints. In psychiatry, an objectively measured brain characteristic that provides clinically useful information is proposed to be that person's "phronotype." Important requirements to developing phronotypes are discussed. Identifying phronotypes in psychiatry will require a specific investigative approach that must be grounded in rigorous scientific methodology. Successfully developing such markers will have a profound impact on clinical care, clinical research, basic science research, and most importantly the lives of those suffering from these illnesses.

The neural circuitry of executive functions in healthy subjects and Parkinson's disease

In our constantly changing environment, we are frequently faced with altered circumstances requiring generation and monitoring of appropriate strategies, when novel plans of action must be formulated and conducted. The abilities that we call upon to respond accurately to novel situations are referred to as 'executive functions', and are frequently engaged to deal with conditions in which routine activation of behavior would not be sufficient for optimal performance. Here, we summarize important findings that may help us understand executive functions and their underlying neuronal correlates. We focus particularly on observations from imaging technology, such as functional magnetic resonance imaging, position emission tomography, diffusion tensor imaging, and transcranial magnetic stimulation, which in the past few years have provided the bulk of information on the neurobiological underpinnings of the executive functions. Further, emphasis will be placed on recent insights from Parkinson's disease (PD), in which the underlying dopaminergic abnormalities have provided new exciting information into basic molecular mechanisms of executive dysfunction, and which may help to disentangle the cortical/subcortical networks involved in executive processes.

An endocrine perspective on the role of steroid hormones in the antidepressant treatment efficacy of transcranial magnetic stimulation

Evidence from recent meta-analyses indicates that transcranial magnetic stimulation (TMS) is moderately effective in the treatment of major depressive disorder (MDD). Individual differences in the susceptibility to TMS are suggested to underlie a significant portion of the variability in antidepressant efficacy observed in TMS trials. Interestingly, recent findings suggest a moderating role for steroid hormones in the antidepressant efficacy of TMS in women. Steroid hormones are known to have strong activational and organizational influences on the brain and may upregulate the efficacy of TMS by way of modulating cortical excitability in a sex-dependent manner. Here we propose that the measurement and manipulation of steroid hormones could be crucial steps in the development of successful individually based TMS protocols for the treatment of MDD.

Modulation of preparatory volitional motor cortical activity by paired associative transcranial magnetic stimulation

Paired associative transcranial magnetic stimulation (PAS) has been shown to induce long-term potentiation (LTP)-like or long-term depression (LTD)-like change in excitability of human primary motor cortex (M1), as probed by motor evoked potential (MEP) amplitude. In contrast, little is known about PAS effects on volitional motor cortical activity. In 10 healthy subjects, movement related cortical potentials (MRCP) were recorded to index volitional motor cortical activity during preparation of simple thumb abduction (prime mover: abductor pollicis brevis, APB) or wrist extension movements (prime mover: extensor carpi radialis, ECR). PAS(LTP) increased, PAS(LTD) decreased, and PAS(control) did not change MEP(APB), while MEP(ECR), not targeted by PAS, remained unchanged in all PAS conditions. PAS(LTP) decreased MRCP negativity during the late Bereitschaftspotential (-500 to 0 ms before movement onset), only in the APB task, and predominantly over central scalp electrodes contralateral to the thumb movements. This effect correlated negatively with the PAS(LTP) induced increase in MEP(APB). PAS(LTD) and PAS(control) did not affect MRCP amplitude. Findings indicate a specific interference of PAS with preparatory volitional motor cortical activity, suggestive of a net result caused by increased M1 excitability and disrupted effective connectivity between premotor areas and M1.