A review of combined TMS-EEG studies to characterize lasting effects of repetitive TMS and assess their usefulness in cognitive and clinical neuroscience

Effect of the combination of high-frequency repetitive magnetic stimulation and neurotropin on injured sciatic nerve regeneration in rats

Repetitive magnetic stimulation is effective for treating posttraumatic neuropathies following spinal or axonal injury. Neurotropin is a potential treatment for nerve injuries like demyelinating diseases. This study sought to observe the effects of high-frequency repetitive magnetic stimulation, neurotropin and their combined use in the treatment of peripheral nerve injury in 32 adult male Sprague-Dawley rats. To create a sciatic nerve injury model, a 10 mm-nerve segment of the left sciatic nerve was cut and rotated through 180° and each end restored continuously with interrupted sutures. The rats were randomly divided into four groups. The control group received only a reversed autograft in the left sciatic nerve with no treatment. In the high-frequency repetitive magnetic stimulation group, peripheral high-frequency repetitive magnetic stimulation treatment (20 Hz, 20 min/d) was delivered for 10 consecutive days after auto-grafting. In the neurotropin group, neurotropin therapy (0.96 NU/kg per day) was administrated for 10 consecutive days after surgery. In the combined group, the combination of peripheral high-frequency repetitive magnetic stimulation (20 Hz, 20 min/d) and neurotropin (0.96 NU/kg per day) was given for 10 consecutive days after the operation. The Basso-Beattie-Bresnahan locomotor rating scale was used to assess the behavioral recovery of the injured nerve. The sciatic functional index was used to evaluate the recovery of motor functions. Toluidine blue staining was performed to determine the number of myelinated fibers in the distal and proximal grafts. Immunohistochemistry staining was used to detect the length of axons marked by neurofilament 200. Our results reveal that the Basso-Beattie-Bresnahan locomotor rating scale scores, sciatic functional index, the number of myelinated fibers in distal and proximal grafts were higher and axon lengths were longer in the high-frequency repetitive magnetic stimulation, neurotropin and combined groups compared with the control group. These measures were not significantly different among the high-frequency repetitive magnetic stimulation, neurotropin and combined groups. Therefore, our results suggest that peripheral high-frequency repetitive magnetic stimulation or neurotropin can promote the repair of injured sciatic nerves, but their combined use seems to offer no significant advantage. This study was approved by the Animal Ethics Committee of the Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, China on December 23, 2014 (approval No. 2014keyan002-01).

The right VLPFC and downregulation of social pain: A TMS study

Previous studies have demonstrated that the right ventrolateral prefrontal cortex (RVLPFC) is crucially involved in downregulating physical and social pain. However, it remains unclear whether the RVLPFC is more specific to either physical or social pain. The present study compares the role of RVLPFC in emotion regulation in physical‐ and social‐pain conditions using repetitive transcranial magnetic stimulation (rTMS). A total of 60 healthy participants underwent active (n = 30) or sham (n = 30) rTMS over the RVLPFC. Following each TMS session, participants performed a non‐reappraisal and then a reappraisal task to downregulate imagined physical or social pain evoked by pictures. Self‐reported negative emotional ratings and electroencephalogram data were recorded during the emotion regulation task. Participants were then required to rate the valence and arousal of those pictures 30 min after the task. It is found that rTMS‐activated RVLPFC led to reductions in subjective negative feelings and amplitudes of the late positive potential during reappraisal; however, these effects were found exclusively in the social‐pain condition. Participants also reported higher positive valence for socially, compared to physically, painful pictures after 30 min of the task. Behavioral and electrophysiological evidence both supported the functional specificity of RVLPFC in regulation of social pain. The prominent delayed effect of rTMS makes it possible to consider the potential application of rTMS‐VLPFC in clinical practice for social pain relief.

Navigated transcranial magnetic stimulation of the supplementary motor cortex disrupts fine motor skills in healthy adults

Navigated transcranial magnetic stimulation (nTMS) over the supplementary motor area (SMA) may impact fine motor skills. This study evaluates different nTMS parameters in their capacity to affect fine motor performance on the way to develop an SMA mapping protocol. Twenty healthy volunteers performed a variety of fine motor tests during baseline and nTMS to the SMA using 5 Hz, 10 Hz, and theta-burst stimulation (TBS). Effects on performance were measured by test completion times (TCTs), standard deviation of inter-tap interval (SDIT), and visible coordination problems (VCPs). The predominant stimulation effect was slowing of TCTs, i.e. a slowdown of test performances during stimulation. Furthermore, participants exhibited VCPs like accidental use of contralateral limbs or inability to coordinate movements. More instances of significant differences between baseline and stimulation occurred during stimulation of the right hemisphere compared to left-hemispheric stimulation. In conclusion, nTMS to the SMA could enable new approaches in neuroscience and enable structured mapping approaches. Specifically, this study supports interhemispheric differences in motor control as right-hemispheric stimulation resulted in clearer impairments. The application of our nTMS-based setup to assess the function of the SMA should be applied in patients with changed anatomo-functional representations as the next step, e.g. among patients with eloquent brain tumors.

Feasibility and clinical effects of theta burst stimulation in youth with major depressive disorders: An open-label trial

BACKGROUND

Conventional treatments for youth depression, such as antidepressants, have modest efficacy, side effects, and ongoing controversies regarding safety. Repetitive transcranial magnetic stimulation (rTMS), specifically theta burst stimulation (TBS), applied to the dorsolateral prefrontal cortex (DLPFC) has demonstrated efficacy for the treatment of depression in adults. However, the feasibility and clinical response to TBS for youth depression has yet to be explored.

METHODS

Twenty participants between the ages of 16 to 24 years old with MDD were recruited. The intervention consisted of 10 treatment sessions over the course of two weeks, in which participants received intermittent TBS and continuous TBS stimulation to the left and right DLPFC, respectively. Change in the Hamilton Rating Scale for Depression (HRSD-17) score was the primary outcome. Clinical assessments occurred at baseline, after the fifth treatment session, and within a week after treatment completion.

RESULTS

Of the twenty participants, eighteen received all TBS sessions, and seventeen completed all clinical assessments. There was a significant reduction in depressive symptoms following treatment completion (p < 0.001). Four of the twenty patients had more than 50% reduction in their depressive symptoms, two of whom achieved remission. All participants received and tolerated at least six daily TBS treatments with no major adverse events.

LIMITATIONS

Study was an uncontrolled, open-label design.

CONCLUSION

Ten sessions of TBS was feasible, well tolerated, and appeared to have clinical effects for the treatment of depressed youth. Future sham-controlled randomized trials are warranted to validate these findings in a larger cohort of youth depression.

Impact of prefrontal intermittent theta-burst stimulation on working memory and executive function in Parkinson's disease: A double-blind sham-controlled pilot study

Cognitive impairment is a prevalent non-motor feature of Parkinson's disease (PD) which can present even in early stages of the disease. Impairments in executive processing and working memory (WM) are common and have been attributed, in part, to abnormalities within the dorsolateral prefrontal cortex (DLPFC) and broader fronto-striatal circuitry. Previous studies in cognitively normal adults have suggested intermittent Theta Burst Stimulation (iTBS), an excitatory plasticity-inducing non-invasive brain stimulation technique, can enhance these cognitive functions. Fourteen participants with a diagnosis of idiopathic PD received either Active or Sham iTBS over the left DLPFC across two separate experimental sessions as part of a double-blind sham-controlled crossover experimental design. The Berg's Card Sorting Test (BCST) and N-Back tasks, which measure executive function and WM respectively, were administered prior to iTBS and again five- and 30-minutes following stimulation. Despite being well-tolerated, iTBS failed to modulate performance on any of the cognitive outcome measures. This finding was further supported by Bayes Factor analyses which indicated moderate levels of support for the null hypothesis overall. This initial pilot study therefore does not support single-session iTBS as an efficacious method for modulating either executive processes or WM in PD. We discuss potential reasons for this finding along with directions for future research.

Persistent Enhancement of Hippocampal Network Connectivity by Parietal rTMS Is Reproducible

Wang et al. (2014) found that that five daily sessions of repetitive transcranial magnetic stimulation (rTMS) of the posterior parietal cortex (PPC) significantly increased functional connectivity (FC) in a network centered on the hippocampus, and caused a correlated increase in memory performance. However, this finding has not been reproduced independently and the requirement for five sessions has not been validated. We aimed to reproduce the imaging results of this experiment, focusing on hippocampal FC changes and using fewer days of rTMS. We measured resting state FC before and after three (N = 9) or four (N = 6) consecutive daily PPC rTMS sessions, using similar delivery parameter settings as Wang et al. (2014). Eight subjects received 3 d of rTMS delivered to the vertex as a control. We employed whole-brain and hypothesis-based statistical approaches to test for hippocampal FC changes. Additionally, we calculated FC in 17 brain networks to determine whether the topographic pattern of FC change was similar between studies. We did not include behavioral testing in this study. PPC, but not vertex, rTMS caused significant changes in hippocampal FC to the same regions as in the previous study. Brain-wide changes in hippocampal FC significantly exceeded changes in global connectedness, indicating that the effect of PPC rTMS was specific to the hippocampal network. Baseline hippocampal FC, measured before receiving stimulation, predicted the degree of rTMS-induced hippocampal FC as in the previous study. These findings reproduce the imaging findings of Wang et al. (2014) and show that FC enhancement can occur after only three to four sessions of PPC rTMS.

Longitudinal increases in structural connectome segregation and functional connectome integration are associated with better recovery after mild TBI

Traumatic brain injury damages white matter pathways that connect brain regions, disrupting transmission of electrochemical signals and causing cognitive and emotional dysfunction. Connectome-level mechanisms for how the brain compensates for injury have not been fully characterized. Here, we collected serial MRI-based structural and functional connectome metrics and neuropsychological scores in 26 mild traumatic brain injury subjects (29.4 ± 8.0 years, 20 males) at 1 and 6 months postinjury. We quantified the relationship between functional and structural connectomes using network diffusion (ND) model propagation time, a measure that can be interpreted as how much of the structural connectome is being utilized for the spread of functional activation, as captured via the functional connectome. Overall cognition showed significant improvement from 1 to 6 months (t25 = -2.15, p = .04). None of the structural or functional global connectome metrics was significantly different between 1 and 6 months, or when compared to 34 age- and gender-matched controls (28.6 ± 8.8 years, 25 males). We predicted longitudinal changes in overall cognition from changes in global connectome measures using a partial least squares regression model (cross-validated R2 = .27). We observe that increased ND model propagation time, increased structural connectome segregation, and increased functional connectome integration were related to better cognitive recovery. We interpret these findings as suggesting two connectome-based postinjury recovery mechanisms: one of neuroplasticity that increases functional connectome integration and one of remote white matter degeneration that increases structural connectome segregation. We hypothesize that our inherently multimodal measure of ND model propagation time captures the interplay between these two mechanisms.

Can Oscillatory Alpha-Gamma Phase-Amplitude Coupling be Used to Understand and Enhance TMS Effects?

Recent applications of simultaneous scalp electroencephalography (EEG) and transcranial magnetic stimulation (TMS) suggest that adapting stimulation to underlying brain states may enhance neuroplastic effects of TMS. It is often assumed that longer-lasting effects of TMS on brain function may be mediated by phasic interactions between TMS pulses and endogenous cortical oscillatory dynamics. The mechanisms by which TMS exerts its neuromodulatory effects, however, remain unknown. Here, we discuss evidence concerning the functional effects on synaptic plasticity of oscillatory cross-frequency coupling in cortical networks as a potential framework for understanding the neuromodulatory effects of TMS. We first discuss evidence for interactions between endogenous oscillatory brain dynamics and externally induced electromagnetic field activity. Alpha band (8-12 Hz) activities are of special interest here because of the wide application and therapeutic effectiveness of rhythmic TMS (rTMS) using a stimulus repetition frequency at or near 10 Hz. We discuss the large body of literature on alpha oscillations suggesting that alpha oscillatory cycles produce periodic inhibition or excitation of neuronal processing through phase-amplitude coupling (PAC) of low-frequency oscillations with high-frequency broadband (or gamma) bursting. Such alpha-gamma coupling may reflect excitability of neuronal ensembles underlying neuroplasticity effects of TMS. We propose that TMS delivery with simultaneous EEG recording and near real-time estimation of source-resolved alpha-gamma PAC might be used to select the precise timing of TMS pulse deliveries so as to enhance the neuroplastic effects of TMS therapies.

Frequency-specific effects of low-intensity rTMS can persist for up to 2 weeks post-stimulation: A longitudinal rs-fMRI/MRS study in rats

BACKGROUND

Evidence suggests that repetitive transcranial magnetic stimulation (rTMS), a non-invasive neuromodulation technique, alters resting brain activity. Despite anecdotal evidence that rTMS effects wear off, there are no reports of longitudinal studies, even in humans, mapping the therapeutic duration of rTMS effects.

OBJECTIVE

Here, we investigated the longitudinal effects of repeated low-intensity rTMS (LI-rTMS) on healthy rodent resting-state networks (RSNs) using resting-state functional MRI (rs-fMRI) and on sensorimotor cortical neurometabolite levels using proton magnetic resonance spectroscopy (MRS).

METHODS

Sprague-Dawley rats received 10 min LI-rTMS daily for 15 days (10 Hz or 1 Hz stimulation, n = 9 per group). MRI data were acquired at baseline, after seven days and after 14 days of daily stimulation and at two more timepoints up to three weeks post-cessation of daily stimulation.

RESULTS

10 Hz stimulation increased RSN connectivity and GABA, glutamine, and glutamate levels. 1 Hz stimulation had opposite but subtler effects, resulting in decreased RSN connectivity and glutamine levels. The induced changes decreased to baseline levels within seven days following stimulation cessation in the 10 Hz group but were sustained for at least 14 days in the 1 Hz group.

CONCLUSION

Overall, our study provides evidence of long-term frequency-specific effects of LI-rTMS. Additionally, the transient connectivity changes following 10 Hz stimulation suggest that current treatment protocols involving this frequency may require ongoing "top-up" stimulation sessions to maintain therapeutic effects.

The effect of psychotropic drugs on cortical excitability and plasticity measured with transcranial magnetic stimulation: Implications for psychiatric treatment

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) is an emerging treatment for neuropsychiatric disorders. Patients in rTMS treatment typically receive concomitant psychotropic medications, which affect neuronal excitability and plasticity and may interact to affect rTMS treatment outcomes. A greater understanding of these drug effects may have considerable implications for optimizing multi-modal treatment of psychiatric patients, and elucidating the mechanism(s) of action (MOA) of rTMS.

METHOD

We summarized the empirical literature that tests how psychotropic drugs affect cortical excitability and plasticity, using varied experimental TMS paradigms.

RESULTS

Glutamate antagonists robustly attenuate plasticity, largely without changes in excitability per se; antiepileptic drugs show the opposite pattern of effects, while calcium channel blockers attenuate plasticity. Benzodiazepines have moderate and variable effects on plasticity, and negligible effects on excitability. Antidepressants with potent 5HT transporter inhibition reduce both excitability and alter plasticity, while antidepressants with other MOAs generally lack either effect. Catecholaminergic drugs, cholinergic agents and lithium have minimal effects on excitability but exhibit robust and complex, non-linear effects in TMS plasticity paradigms.

LIMITATIONS

These effects remain largely untested in sustained treatment protocols, nor in clinical populations. In addition, how these medications impact clinical response to rTMS remains largely unknown.

CONCLUSIONS

Psychotropic medications exert robust and varied effects on cortical excitability and plasticity. We encourage the field to more directly and fully investigate clinical pharmaco-TMS studies to improve outcomes.

Early Electrophysiological Disintegration of Hippocampal Neural Networks in a Novel Locus Coeruleus Tau-Seeding Mouse Model of Alzheimer's Disease

Alzheimer's disease (AD) is a progressive, neurodegenerative disease characterized by loss of synapses and disrupted functional connectivity (FC) across different brain regions. Early in AD progression, tau pathology is found in the locus coeruleus (LC) prior to amyloid-induced exacerbation of clinical symptoms. Here, a tau-seeding model in which preformed synthetic tau fibrils (K18) were unilaterally injected into the LC of P301L mice, equipped with multichannel electrodes for recording EEG in frontal cortical and CA1-CA3 hippocampal areas, was used to longitudinally quantify over 20 weeks of functional network dynamics in (1) power spectra; (2) FC using intra- and intersite phase-amplitude theta-gamma coupling (PAC); (3) coherence, partial coherence, and global coherent network efficiency (Eglob) estimates; and (4) the directionality of functional connectivity using extended partial direct coherence (PDC). A sustained leftward shift in the theta peak frequency was found early in the power spectra of hippocampal CA1 networks ipsilateral to the injection site. Strikingly, hippocampal CA1 coherence and Eglob measures were impaired in K18-treated animals. Estimation of instantaneous EEG amplitudes revealed deficiency in the propagation directionality of gamma oscillations in the CA1 circuit. Impaired PAC strength evidenced by decreased modulation of the theta frequency phase on gamma frequency amplitude further confirms impairments of the neural CA1 network. The present results demonstrate early dysfunctional hippocampal networks, despite no spreading tau pathology to the hippocampus and frontal cortex. The ability of the K18 seed in the brainstem LC to elicit such robust functional alterations in distant hippocampal structures in the absence of pathology challenges the classic view that tau pathology spread to an area is necessary to elicit functional impairments in that area.

Modulation of the rubber hand illusion by transcranial direct current stimulation over the contralateral somatosensory cortex

In the rubber hand illusion (RHI), illusory bodily ownership is induced by synchronous touch of a participant's hidden hand and a visible surrogate. This paradigm allows investigating how the brain resolves conflicting multisensory evidence during perceptual inference. Previous studies suggest that the conflict between visual and proprioceptive information preceding the RHI is solved by attenuation of the somatosensory input. To investigate whether excitability-decreasing transcranial direct current stimulation (cathodal tDCS) over the primary somatosensory cortex may enhance the RHI, thirty healthy subjects underwent RHI without (baseline) and during tDCS. Each subject received cathodal, anodal, and sham stimulation at independent sessions on three separate days. The RHI paradigm was applied at six interval distances between the real and artificial hand. Occurrence of the RHI was evaluated by a questionnaire (illusion score) and the perceived hand misplacement (relative drift). Compared to sham, neither cathodal, nor anodal tDCS induced significant changes of the illusion score. However, cathodal tDCS was associated with significantly higher illusion scores compared to anodal stimulation. The relative drift was comparable between stimulation modes. Our findings point to a differential impact of cathodal vs. anodal tDCS over the somatosensory region on RHI perception. This may indicate that an attenuation - in contrast to an enhancement - of somatosensory precision might pave the way for the integration of an artificial limb into one's body schema.

Prolonged Neuromodulation of Cortical Networks Following Low-Frequency rTMS and Its Potential for Clinical Interventions

Non-invasive brain stimulation safely induces persistent large-scale neural modulation in functionally connected brain circuits. Interruption models of repetitive transcranial magnetic stimulation (rTMS) capitalize on the acute impact of brain stimulation, which decays over minutes. However, rTMS also induces longer-lasting impact on cortical functions, evident by the use of multi-session rTMS in clinical population for therapeutic purposes. Defining the persistent cortical dynamics induced by rTMS is complicated by the complex balance of excitation and inhibition among functionally connected networks. Nonetheless, it is these neuronal dynamic responses that are essential for the development of new neuromodulatory protocols for translational applications. We will review evidence of prolonged changes of cortical response, tens of minutes following one session of low frequency rTMS over the cortex. We will focus on the different methods which resulted in prolonged behavioral and brain changes, such as the combination of brain stimulation techniques, and individually tailored stimulation protocols. We will also highlight studies which apply these methods in multi-session stimulation practices to extend stimulation impact into weeks and months. Our data and others' indicate that delayed cortical dynamics may persist much longer than previously thought and have potential as an extended temporal window during which cortical plasticity may be enhanced.

A novel approach for assessing neuromodulation using phase-locked information measured with TMS-EEG

Neuromodulation therapies such as electroconvulsive therapy (ECT) are used to treat several neuropsychiatric disorders, including major depressive disorder (MDD). Recent work has highlighted the use of combined transcranial magnetic stimulation and electroencephalography (TMS-EEG) to evaluate the therapeutic effects of neuromodulation; particularly, the phase locking factor (PLF) and phase locking value (PLV) can reportedly assess neuromodulation-induced functional changes in cortical networks. To examine changes in TMS-induced PLV and PLF before and after ECT, and their relationship with depression severity in patients with MDD, TMS-EEG and the Montgomery–Åsberg Depression Rating Scale (MADRS; depression severity) were implemented before and after ECT in 10 patients with MDD. Single-pulse TMS was applied to the visual and motor areas to induce phase propagation in the visuo-motor network at rest. Functional changes were assessed using PLF and PLV data. Pre-ECT TMS-induced alpha band (9–12 Hz) PLV was negatively correlated with depression severity, and increments of post-ECT from pre-ECT TMS-induced alpha band PLV were positively correlated with the reduction in depression severity. Moreover, we found a negative correlation between pre-ECT TMS-induced PLF at TMS-destination and depression severity. Finally, differences in post-ECT TMS-induced PLF peak latencies between visual and motor areas were positively correlated with depression severity. TMS-EEG-based PLV and PLF may be used to assess the therapeutic effects of neuromodulation and depressive states, respectively. Furthermore, our results provide new insights about the neural mechanisms of ECT and depression.

Effects of Acoustic Paired Associative Stimulation on Late Auditory Evoked Potentials

Paired associative stimulation (PAS), a form of non-invasive cortical stimulation pairing transcranial magnetic stimulation (TMS) with a peripheral sensory stimulus, has been shown to induce neuroplastic effects in the human motor, somatosensory and auditory cortex. The current study investigated the effects of acoustic PAS on late auditory evoked potentials (LAEP) and the influence of tone duration and placebo stimulation. In two experiments, 18 participants underwent a PAS with a 4 kHz paired tone of 400 ms duration using 200 pairs of stimuli (TMS-pulse over the left auditory cortex 45 ms after tone-onset) presented at 0.1 Hz. In Experiment 1 this protocol was contrasted with a protocol using a short paired tone of 23 ms duration (PAS-23 ms vs. PAS-400 ms). In Experiment 2 this PAS protocol was contrasted with sham stimulation (PAS-400 ms-sham vs. PAS-400 ms). Before and after PAS, LAEP were recorded for tones of 4 kHz (same carrier frequency as the paired tone) and 1 kHz as control tone. In Experiment 1, there was a significant difference between LAEP amplitudes of the 4 kHz tone after PAS-23 ms and PAS-400 ms with higher LAEP amplitudes after PAS-23 ms. Before both conditions, no difference could be detected. In Experiment 2 we observed a significant overall decrease in LAEP amplitudes pre to post PAS. Unspecific decreases of LAEP following PAS with a long paired tone (PAS-400 ms) might be related to habituation effects due to repeated presentation of sound stimuli which are not evident for PAS with a short paired tone (PAS-23 ms). Interpreting this result using the concept of temporal integration time allows us to discuss it in the context of spike-timing dependent plasticity.

Frequency-specific noninvasive modulation of memory retrieval and its relationship with hippocampal network connectivity

Episodic memory is thought to rely on interactions of the hippocampus with other regions of the distributed hippocampal-cortical network (HCN) via interregional activity synchrony in the theta frequency band. We sought to causally test this hypothesis using network-targeted transcranial magnetic stimulation. Healthy human participants completed four experimental sessions, each involving a different stimulation pattern delivered to the same individualized parietal cortex location of the HCN for all sessions. There were three active stimulation conditions, including continuous theta-burst stimulation, intermittent theta-burst stimulation, and beta-frequency (20-Hz) repetitive stimulation, and one sham condition. Resting-state fMRI and episodic memory testing were used to assess the impact of stimulation on hippocampal fMRI connectivity related to retrieval success. We hypothesized that theta-burst stimulation conditions would most strongly influence hippocampal-HCN fMRI connectivity and retrieval, given the hypothesized relevance of theta-band activity for HCN memory function. Continuous theta-burst stimulation improved item retrieval success relative to sham and relative to beta-frequency stimulation, whereas intermittent theta-burst stimulation led to numerical but nonsignificant item retrieval improvement. Mean hippocampal fMRI connectivity did not vary for any stimulation conditions, whereas individual differences in retrieval improvements due to continuous theta-burst stimulation were associated with corresponding increases in fMRI connectivity between the hippocampus and other HCN locations. No such memory-related connectivity effects were identified for the other stimulation conditions, indicating that only continuous theta-burst stimulation affected memory-related hippocampal-HCN connectivity. Furthermore, these effects were specific to the targeted HCN, with no significant memory-related fMRI connectivity effects for two distinct control brain networks. These findings support a causal role for fMRI connectivity of the hippocampus with the HCN in episodic memory retrieval and indicate that contributions of this network to retrieval are particularly sensitive to continuous theta-burst noninvasive stimulation.

Effects of low- and high-frequency repetitive transcranial magnetic stimulation on long-latency auditory evoked potentials

Long-latency auditory event potentials (LLAEPs) involving local and global auditory processes have been investigated to examine the impact of low-frequency (LF) and high-frequency (HF) repetitive transcranial magnetic stimulation (rTMS) on the cortical excitability of the temporal cortex. We hypothesized that both stimulation frequencies have the same modulation effect, in accordance with clinical data showing a reduction in auditory verbal hallucinations (AVHs) after LF and HF temporal rTMS in patients with schizophrenia. With 30 right-handed healthy volunteer participants enrolled in a crossover trial, we analyzed LLAEPs before and after LF- and HF-rTMS of the left temporal cortex. While we observed no changes in latencies, we did observe a similar inhibitory action of both rTMS frequencies on LLAEP amplitudes. Analysis of surface potential maps and cortical generators revealed some differences regarding auditory processes: HF-rTMS produced earlier, more diffuse, and more right-lateralized effects than LF-rTMS. Beyond a local impact, rTMS exerted a remote modulation influence on the frontal cortex that might be involved in attentional processes. This association could explain the therapeutic effect of temporal HF-rTMS on AVH.

Focal application of accelerated iTBS results in global changes in graph measures

Graph analysis was used to study the effects of accelerated intermittent theta burst stimulation (aiTBS) on the brain's network topology in medication‐resistant depressed patients. Anatomical and resting‐state functional MRI (rs‐fMRI) was recorded at baseline and after sham and verum stimulation. Depression severity was assessed using the Hamilton Depression Rating Scale (HDRS). Using various graph measures, the different effects of sham and verum aiTBS were calculated. It was also investigated whether changes in graph measures were correlated to clinical responses. Furthermore, by correlating baseline graph measures with the changes in HDRS in terms of percentage, the potential of graph measures as biomarker was studied. Although no differences were observed between the effects of verum and sham stimulation on whole‐brain graph measures and changes in graph measures did not correlate with clinical response, the baseline values of clustering coefficient and global efficiency showed to be predictive of the clinical response to verum aiTBS. Nodal effects were found throughout the whole brain. The distribution of these effects could not be linked to the strength of the functional connectivity between the stimulation site and the node. This study showed that the effects of aiTBS on graph measures distribute beyond the actual stimulation site. However, additional research into the complex interactions between different areas in the brain is necessary to understand the effects of aiTBS in more detail.

The effects of individualised intermittent theta burst stimulation in the prefrontal cortex: A TMS-EEG study

Recent studies have highlighted variability in response to theta burst stimulation (TBS) in humans. TBS paradigm was originally developed in rodents to mimic gamma bursts coupled with theta rhythms, and was shown to elicit long-term potentiation. The protocol was subsequently adapted for humans using standardised frequencies of stimulation. However, each individual has different rhythmic firing pattern. The present study sought to explore whether individualised intermittent TBS (Ind iTBS) could outperform the effects of two other iTBS variants. Twenty healthy volunteers received iTBS over left prefrontal cortex using 30 Hz at 6 Hz, 50 Hz at 5 Hz, or individualised frequency in separate sessions. Ind iTBS was determined using theta-gamma coupling during the 3-back task. Concurrent use of transcranial magnetic stimulation and electroencephalography (TMS-EEG) was used to track changes in cortical plasticity. We also utilised mood ratings using a visual analogue scale and assessed working memory via the 3-back task before and after stimulation. No group-level effect was observed following either 30 or 50 Hz iTBS in TMS-EEG. Ind iTBS significantly increased the amplitude of the TMS-evoked P60, and decreased N100 and P200 amplitudes. A significant positive correlation between neurophysiological change and change in mood rating was also observed. Improved accuracy in the 3-back task was observed following both 50 Hz and Ind iTBS conditions. These findings highlight the critical importance of frequency in the parameter space of iTBS. Tailored stimulation parameters appear more efficacious than standard paradigms in neurophysiological and mood changes. This novel approach presents a promising option and benefits may extend to clinical applications.

Effects of Hand Training During the Aftereffect Period of Low-Frequency rTMS in Subacute Stroke Patients

Objective

To investigate the effects of hand training using low-frequency repetitive transcranial magnetic stimulation (rTMS) within the aftereffect period on hand function in patients with subacute stroke.

Methods

The subacute stroke patients with hand weaknesses were divided randomly into two groups. Patients in the intervention group underwent hand training within the aftereffect period, that is, immediately after receiving low-frequency rTMS treatment. Patients in the control group underwent hand training 2 hours after the low-frequency rTMS treatment. A manual function test (MFT) for ‘grasp and pinch’ and ‘hand activities’; a manual muscle test (MMT) for ‘grasp’, ‘release’, and ‘abductor pollicis brevis (APB)’; and the Modified Ashworth Scale for finger flexion were performed and measured before and immediately after combined therapy as well as 2 weeks after combined therapy.

Results

Thirty-two patients with hand weakness were enrolled in this study. The intervention group patients showed more improvements in grasp MMT and MMT APB tested immediately after combined therapy. However, the changes in all measurements were not significantly different between the two groups 2 weeks after the combined therapy. In both groups, hand functions improved significantly immediately after combined therapy and 2 weeks after combined therapy.

Conclusion

Hand training immediately after low-frequency rTMS showed more rapid improvement in the motor power of hands than hand training conducted 2 hours after low-frequency rTMS. Our results suggest that conducting hand training immediately after low-frequency rTMS could be an improved useful therapeutic option in subacute stroke patients.

The posterior parietal cortex and subjectively perceived confidence during memory retrieval

Functional neuroimaging studies suggest a role for the left angular gyrus (AG) in processes related to memory recognition. However, results of neuropsychological and transcranial magnetic stimulation (TMS) studies have been inconclusive regarding the specific contribution of the AG in recollection, familiarity, and the subjective experience of memory. To obtain further insight into this issue, 20 healthy right-handed volunteers performed a memory task in a single-blind within-subject controlled TMS study. Neuronavigated inhibitory repetitive TMS (rTMS) was applied over the left AG and the vertex in a randomized and counterbalanced order. Prior to rTMS participants were presented with a list of words. After rTMS participants were shown a second list of words and instructed to indicate if the word was already shown prior to rTMS ("old") or was presented for the first time ("new"). In addition, subjectively perceived memory confidence was assessed. Results showed that recollection was unaffected following inhibitory left AG rTMS. In contrast, rTMS over the left AG improved both familiarity and the subjectively perceived confidence of participants that demonstrated low baseline memory recognition. Our study highlights the importance of taking into account individual differences in experimental designs involving noninvasive brain stimulation.

Causal Evidence for Mnemonic Metacognition in Human Precuneus

Metacognition is the capacity to introspectively monitor and control one's own cognitive processes. Previous anatomical and functional neuroimaging findings implicated the important role of the precuneus in metacognition processing, especially during mnemonic tasks. However, the issue of whether this medial parietal cortex is a domain-specific region that supports mnemonic metacognition remains controversial. Here, we focally disrupted this parietal area with repetitive transcranial magnetic stimulation in healthy human participants of both sexes, seeking to ascertain its functional necessity for metacognition in memory versus perceptual decisions. Perturbing precuneal activity selectively impaired metacognitive efficiency of temporal-order memory judgment, but not perceptual discrimination. Moreover, the correlation in individuals' metacognitive efficiency between domains disappeared when the precuneus was perturbed. Together, these findings provide evidence reinforcing the notion that the precuneal region plays an important role in mediating metacognition of episodic memory retrieval.SIGNIFICANCE STATEMENT Theories on the neural basis of metacognition have thus far been largely centered on the role of the prefrontal cortex. Here we refined the theoretical framework through characterizing a unique precuneal involvement in mnemonic metacognition with a noninvasive but inferentially powerful method: transcranial magnetic stimulation. By quantifying metacognitive efficiency across two distinct domains (memory vs perception) that are matched for stimulus characteristics, we reveal an instrumental role of the precuneus in mnemonic metacognition. This causal evidence corroborates ample clinical reports that parietal lobe lesions often produce inaccurate self-reports of confidence in memory recollection and establish the precuneus as a nexus for the introspective ability to evaluate the success of memory judgment in humans.

Induction and Quantification of Excitability Changes in Human Cortical Networks

How does human brain stimulation result in lasting changes in cortical excitability? Uncertainty on this question hinders the development of personalized brain stimulation therapies. To characterize how cortical excitability is altered by stimulation, we applied repetitive direct electrical stimulation in eight human subjects (male and female) undergoing intracranial monitoring. We evaluated single-pulse corticocortical-evoked potentials (CCEPs) before and after repetitive stimulation across prefrontal (n = 4), temporal (n = 1), and motor (n = 3) cortices. We asked whether a single session of repetitive stimulation was sufficient to induce excitability changes across distributed cortical sites. We found a subset of regions at which 10 Hz prefrontal repetitive stimulation resulted in both potentiation and suppression of excitability that persisted for at least 10 min. We then asked whether these dynamics could be modeled by the prestimulation connectivity profile of each subject. We found that cortical regions (1) anatomically close to the stimulated site and (2) exhibiting high-amplitude CCEPs underwent changes in excitability following repetitive stimulation. We demonstrate high accuracy (72-95%) and discriminability (81-99%) in predicting regions exhibiting changes using individual subjects' prestimulation connectivity profile, and show that adding prestimulation connectivity features significantly improved model performance. The same features predicted regions of modulation following motor and temporal cortices stimulation in an independent dataset. Together, baseline connectivity profile can be used to predict regions susceptible to brain changes and provides a basis for personalizing brain stimulation.SIGNIFICANCE STATEMENT Brain stimulation is increasingly used to treat neuropsychiatric disorders by inducing excitability changes at specific brain regions. However, our understanding of how, when, and where these changes are induced is critically lacking. We inferred plasticity in the human brain after applying electrical stimulation to the brain's surface and measuring changes in excitability. We observed excitability changes in regions anatomically and functionally closer to the stimulation site. Those in responsive regions were accurately predicted using a classifier trained on baseline brain network characteristics. Finally, we showed that the excitability changes can potentially be monitored in real-time. These results begin to fill basic gaps in our understanding of stimulation-induced brain dynamics in humans and offer pathways to optimize stimulation protocols.

Interventional programmes to improve cognition during healthy and pathological ageing: Cortical modulations and evidence for brain plasticity

A growing body of evidence suggests that healthy elderly individuals and patients with Alzheimer's disease retain an important potential for neuroplasticity. This review summarizes studies investigating the modulation of neural activity and structural brain integrity in response to interventions involving cognitive training, physical exercise and non-invasive brain stimulation in healthy elderly and cognitively impaired subjects (including patients with mild cognitive impairment (MCI) and Alzheimer's disease). Moreover, given the clinical relevance of neuroplasticity, we discuss how evidence for neuroplasticity can be inferred from the functional and structural brain changes observed after implementing these interventions. We emphasize that multimodal programmes, which combine several types of interventions, improve cognitive function to a greater extent than programmes that use a single interventional approach. We suggest specific methods for weighting the relative importance of cognitive training, physical exercise and non-invasive brain stimulation according to the functional and structural state of the brain of the targeted subject to maximize the cognitive improvements induced by multimodal programmes.

The theta burst transcranial magnetic stimulation over the right PFC affects electroencephalogram oscillation during emotional processing

Prefrontal cortex (PFC) plays an important role in emotional processing and therefore is one of the most frequently targeted regions for non-invasive brain stimulation such as repetitive transcranial magnetic stimulation (rTMS) in clinical trials, especially in the treatment of emotional disorders. As an approach to enhance the effectiveness of rTMS, continuous theta burst stimulation (cTBS) has been demonstrated to be efficient and safe. However, it is unclear how cTBS affects brain processes related to emotion. In particular, psychophysiological studies on the underlying neural mechanisms are sparse. In the current study, we investigated how the cTBS influences emotional processing when applied over the right PFC. Participants performed an emotion recognition Go/NoGo task, which asked them to select a GO response to either happy or fearful faces after the cTBS or after sham stimulation, while 64-channel electroencephalogram (EEG) was recorded. EEG oscillation was examined using event-related spectral perturbation (ERSP) in a time-interval between 170 and 310ms after face stimuli onset. In the sham group, we found a significant difference in the alpha band between response to happy and fearful stimuli but that effect did not exist in the cTBS group. The alpha band activity at the scalp was reduced suggesting the excitatory effect at the brain level. The beta and gamma band activity was not sensitive to cTBS intervention. The results of the current study demonstrate that cTBS does affect emotion processing and the effect is reflected in changes in EEG oscillations in the alpha band specifically. The results confirm the role of prefrontal cortex in emotion processing. We also suggest that this pattern of cTBS results elucidates mechanisms by which mood improvement in depressive disorders is achieved using cTBS intervention.

Prefrontal θ-Burst Stimulation Disrupts the Organizing Influence of Active Short-Term Retrieval on Episodic Memory

Dorsolateral prefrontal cortex (DLPFC) is thought to organize items in working memory and this organizational role may also influence long-term memory. To causally test this hypothesized role of DLPFC in long-term memory formation, we used θ-burst noninvasive stimulation (TBS) to modulate DLPFC involvement in a memory task that assessed the influence of active short-term retrieval on later memory. Human subjects viewed three objects on a grid and then either actively retrieved or passively restudied one object’s location after a brief delay. Long-term memory for the other objects was assessed after a delay to evaluate the beneficial role of active short-term retrieval on subsequent memory for the entire set of object locations. We found that DLPFC TBS had no significant effects on short-term memory. In contrast, DLPFC TBS impaired long-term memory selectively in the active-retrieval condition but not in the passive-restudy condition. These findings are consistent with the hypothesized contribution of DLPFC to the organizational processes operative during active short-term retrieval that influence long-term memory, although other regions that were not stimulated could provide similar contributions. Notably, active-retrieval and passive-restudy conditions were intermixed, and therefore nonspecific influences of stimulation were well controlled. These results suggest that DLPFC is causally involved in organizing event information during active retrieval to support coherent long-term memory formation.

Transcranial magnetic stimulation studies in complex regional pain syndrome type I: A review

The sensory and motor cortical representation corresponding to the affected limb is altered in patients with complex regional pain syndrome (CRPS). Transcranial magnetic stimulation (TMS) represents a useful non-invasive approach for studying cortical physiology. If delivered repetitively, TMS can also modulate cortical excitability and induce long-lasting neuroplastic changes. In this review, we performed a systematic search of all studies using TMS to explore cortical excitability/plasticity and repetitive TMS (rTMS) for the treatment of CRPS. Literature searches were conducted using PubMed and EMBASE. We identified 8 articles matching the inclusion criteria. One hundred fourteen patients (76 females and 38 males) were included in these studies. Most of them have applied TMS in order to physiologically characterize CRPS type I. Changes in motor cortex excitability and brain mapping have been reported in CRPS-I patients. Sensory and motor hyperexcitability are in the most studies bilateral and likely involve corresponding regions within the central nervous system rather than the entire hemisphere. Conversely, sensorimotor integration and plasticity were found to be normal in CRPS-I. TMS examinations also revealed that the nature of motor dysfunction in CRPS-I patients differs from that observed in patients with functional movement disorders, limb immobilization, or idiopathic dystonia. TMS studies may thus lead to the implementation of correct rehabilitation strategies in CRPS-I patients. Two studies have begun to therapeutically use rTMS. This non-invasive brain stimulation technique could have therapeutic utility in CRPS, but further well-designed studies are needed to corroborate initial findings.

Resting-State Alpha-Band Oscillations in Migraine

Migraine groups show differences in motion perception compared with controls, when tested in between migraine attacks (interictally). This is thought to be due to an increased susceptibility to stimulus degradation (multiplicative internal noise). Fluctuations in alpha-band oscillations are thought to regulate visual perception, and so differences could provide a mechanism for the increased multiplicative noise seen in migraine. The aim of this article was to characterise resting-state alpha-band oscillations (between 8 and 12 Hz) in the visual areas of the brain in migraine and control groups. Alpha-band activity in the resting state (with eyes closed) was recorded before and after a visual psychophysics task to estimate equivalent noise, specifically a contrast detection task. The lower alpha-band (8 to 10 Hz) resting-state alpha-band power was increased in the migraine compared with the control group, which may provide a mechanism for increased multiplicative noise. In agreement with previous research, there were no differences found in the additive (baseline) internal noise, estimated using an equivalent noise task in the same observers. As fluctuations in alpha-band oscillations control the timing of perceptual processing, increased lower alpha-band (8 to 10 Hz) power could explain the behavioural differences in migraine compared with control groups, particularly on tasks relying on temporal integration.

Biological, Neuroimaging, and Neurophysiological Markers in Frontotemporal Dementia: Three Faces of the Same Coin

Frontotemporal dementia (FTD) is a heterogeneous clinical, genetic, and neuropathological disorder. Clinical diagnosis and prediction of neuropathological substrates are hampered by heterogeneous pictures. Diagnostic markers are key in clinical trials to differentiate FTD from other neurodegenerative dementias. In the same view, identifying the neuropathological hallmarks of the disease is key in light of future disease-modifying treatments. The aim of the present review is to unravel the progress in biomarker discovery, discussing the potential applications of available biological, imaging, and neurophysiological markers.

The use of MR‑less MNI based neuronavigation for 10 Hz rTMS depression therapy: electrophysiological and clinical implications

Repetitive transcranial magnetic stimulation (rTMS) is a popular and effective treatment for drug resistant depression. However, there is considerable variability in clinical outcomes, in previous studies and between patients. Because of high requirements for the use of fMRI based neuronavigation, many practitioners of rTMS still choose to use a standard 5 cm rule for rTMS coil placement which leads to large variations in which brain regions are being stimulated. We decided to test the possibilities of a MNI based MR‑less neuronavigation system in rTMS depression treatment, by comparing the physiological effects and clinical outcomes of 3 distinct stimulation targets. Forty‑six patients (thirty‑three female, thirteen male) from the Republican Vilnius psychiatric hospital, all with drug resistant depressive disorder, participated in the study. All patients received high frequency (10 Hz) stimulation for 10 to 15 daily rTMS sessions. However, before the treatment they were randomly sorted into 3 groups according to stimulation target in MNI map: Group 1 received rTMS at point ‑40; 48; 35; Group 2 received rTMS at point ‑46; 45; 38; Group 3 received rTMS at point ‑38; 44; 26. Electroencephalography (EEG) recordings and clinical tests were obtained the day before the rTMS course and after the last session. There were some notable differences in physiological changes between the groups, with the largest EEG band spectral power increases found in Group 1 patients and the lowest in Group 2 patients. There was a significantly larger decrease of the Hamilton Depression Rating Scale (HAM-D) scores in the Group 3 (66.94%) compared to Group 1 (57.52%) and Group 2 (56.02%). This suggests it is possible to achieve higher clinical efficacy and less physiological impact on the brain when using different targets in a neuronavigated MNI based MR‑less rTMS system.

A Causal Role of the Right Superior Temporal Sulcus in Emotion Recognition From Biological Motion

Understanding the emotions of others through nonverbal cues is critical for successful social interactions. The right posterior superior temporal sulcus (pSTS) is one brain region thought to be key in the recognition of the mental states of others based on body language and facial expression. In the present study, we temporarily disrupted functional activity of the right pSTS by using continuous, theta-burst transcranial magnetic stimulation (cTBS) to test the hypothesis that the right pSTS plays a causal role in emotion recognition from body movements. Participants ( N = 23) received cTBS to the right pSTS, which was individually localized using fMRI, and a vertex control site. Before and after cTBS, we tested participants’ ability to identify emotions from point-light displays (PLDs) of biological motion stimuli and a nonbiological global motion identification task. Results revealed that accurate identification of emotional states from biological motion was reduced following cTBS to the right pSTS, but accuracy was not impaired following vertex stimulation. Accuracy on the global motion task was unaffected by cTBS to either site. These results support the causal role of the right pSTS in decoding information about others’ emotional state from their body movements and gestures.

Retaliation or selfishness? An rTMS investigation of the role of the dorsolateral prefrontal cortex in prosocial motives

Equity, fairness and cooperative behavior are crucial for everyday social interactions. Recent neuroimaging studies suggest that the dorsolateral prefrontal cortex (DLPFC) is involved in the evaluation of violations of fairness rules, though difficulties remain to determine its role in implementing retaliating or forgiving responses to unfairness. Accordingly, we applied repetitive transcranial magnetic stimulation (rTMS) to the left and right DLPFC and investigated the impact of the DLPFC on retaliation and selfishness using a sequential neuroeconomic task establishing a role reversal. That is, participants first played an Ultimatum Game (in the role of a recipient) against fair or unfair proposers, followed by a Dictator Game in the role of a proposer. Following inhibition of the right DLPFC, subjects showed an increased punishment rate regarding previously unfair opponents. Surprisingly, previously fair opponents were also treated less fairly after rTMS to the right DLPFC, but not after left or sham rTMS. Previous work suggests that the right DLPFC provides "top-down" cognitive control over prepotent emotional responses to unfairness. Our results indicate, however, that the right DLPFC may be involved in controlling selfish behavior and that its suppression leads to maximization of one's own benefit, regardless of another's fairness or unfairness in previous encounters.

The Effects of rTMS Combined with Motor Training on Functional Connectivity in Alpha Frequency Band

It has recently been reported that repetitive transcranial magnetic stimulation combined with motor training (rTMS-MT) could improve motor function in post-stroke patients. However, the effects of rTMS-MT on cortical function using functional connectivity and graph theoretical analysis remain unclear. Ten healthy subjects were recruited to receive rTMS immediately before application of MT. Low frequency rTMS was delivered to the dominant hemisphere and non-dominant hand performed MT over 14 days. The reaction time of Nine-Hole Peg Test and electroencephalography (EEG) in resting condition with eyes closed were recorded before and after rTMS-MT. Functional connectivity was assessed by phase synchronization index (PSI), and subsequently thresholded to construct undirected graphs in alpha frequency band (8–13 Hz). We found a significant decrease in reaction time after rTMS-MT. The functional connectivity between the parietal and frontal cortex, and the graph theory statistics of node degree and efficiency in the parietal cortex increased. Besides the functional connectivity between premotor and frontal cortex, the degree and efficiency of premotor cortex showed opposite results. In addition, the number of connections significantly increased within inter-hemispheres and inter-regions. In conclusion, this study could be helpful in our understanding of how rTMS-MT modulates brain activity. The methods and results in this study could be taken as reference in future studies of the effects of rTMS-MT in stroke patients.

Improving the quality of combined EEG-TMS neural recordings: Introducing the coil spacer

BACKGROUND

In the last decade, interest in combined transcranial magnetic stimulation (TMS) and electroencephalography (EEG) approaches has grown substantially. Aside from the obvious artifacts induced by the magnetic pulses themselves, separate and more sinister signal disturbances arise as a result of contact between the TMS coil and EEG electrodes.

NEW METHOD

Here we profile the characteristics of these artifacts and introduce a simple device - the coil spacer - to provide a platform allowing physical separation between the coil and electrodes during stimulation.

RESULTS

EEG data revealed high amplitude signal disturbances when the TMS coil was in direct contact with the EEG electrodes, well within the physiological range of viable EEG signals. The largest artifacts were located in the Delta and Theta frequency range, and standard data cleanup using independent components analysis (ICA) was ineffective due to the artifact's similarity to real brain oscillations.

COMPARISON WITH EXISTING METHOD

While the current best practice is to use a large coil holding apparatus to fixate the coil 'hovering' over the head with an air gap, the spacer provides a simpler solution that ensures this distance is kept constant throughout testing.

CONCLUSIONS

The results strongly suggest that data collected from combined TMS-EEG studies with the coil in direct contact with the EEG cap are polluted with low frequency artifacts that are indiscernible from physiological brain signals. The coil spacer provides a cheap and simple solution to this problem and is recommended for use in future simultaneous TMS-EEG recordings.

cTBS disruption of the supplementary motor area perturbs cortical sequence representation but not behavioural performance

Neuroimaging studies have repeatedly emphasized the role of the supplementary motor area (SMA) in motor sequence learning, but interferential approaches have led to inconsistent findings. Here, we aimed to test the role of the SMA in motor skill learning by combining interferential and neuroimaging techniques. Sixteen subjects were trained on simple finger movement sequences for 4 days. Afterwards, they underwent two neuroimaging sessions, in which they executed both trained and novel sequences. Prior to entering the scanner, the subjects received inhibitory transcranial magnetic stimulation (TMS) over the SMA or a control site. Using multivariate fMRI analysis, we confirmed that motor training enhances the neural representation of motor sequences in the SMA, in accordance with previous findings. However, although SMA inhibition altered sequence representation (i.e. between-sequence decoding accuracy) in this area, behavioural performance remained unimpaired. Our findings question the causal link between the neuroimaging correlate of elementary motor sequence representation in the SMA and sequence generation, calling for a more thorough investigation of the role of this region in performance of learned motor sequences.

Contribution of transcranial magnetic stimulation to assessment of brain connectivity and networks

The goal of this review is to show how transcranial magnetic stimulation (TMS) techniques can make a contribution to the study of brain networks. Brain networks are fundamental in understanding how the brain operates. Effects on remote areas can be directly observed or identified after a period of stimulation, and each section of this review will discuss one method. EEG analyzed following TMS is called TMS-evoked potentials (TEPs). A conditioning TMS can influence the effect of a test TMS given over the motor cortex. A disynaptic connection can be tested also by assessing the effect of a pre-conditioning stimulus on the conditioning-test pair. Basal ganglia-cortical relationships can be assessed using electrodes placed in the process of deep brain stimulation therapy. Cerebellar-cortical relationships can be determined using TMS over the cerebellum. Remote effects of TMS on the brain can be found as well using neuroimaging, including both positron emission tomography (PET) and functional magnetic resonance imaging (fMRI). The methods complement each other since they give different views of brain networks, and it is often valuable to use more than one technique to achieve converging evidence. The final product of this type of work is to show how information is processed and transmitted in the brain.

Impact of Prefrontal Theta Burst Stimulation on Clinical Neuropsychological Tasks

Theta burst stimulation (TBS) protocols hold high promise in neuropsychological rehabilitation. Nevertheless, their ability to either decrease (continuous, cTBS) or increase (intermittent, iTBS) cortical excitability in areas other than the primary motor cortex, and their consistency modulating human behaviors with clinically relevant tasks remain to be fully established. The behavioral effects of TBS over the dorsolateral prefrontal cortex (dlPFC) are particularly interesting given its involvement in working memory (WM) and executive functions (EF), often impaired following frontal brain damage. We aimed to explore the ability of cTBS and iTBS to modulate WM and EF in healthy individuals, assessed with clinical neuropsychological tests (Digits Backward, 3-back task, Stroop Test, and Tower of Hanoi). To this end, 36 participants were assessed using the four tests 1 week prior to stimulation and immediately following a single session of either cTBS, iTBS, or sham TBS, delivered to the left dlPFC. No significant differences were found across stimulation conditions in any of the clinical tasks. Nonetheless, in some of them, active stimulation induced significant pre/post performance modulations, which were not found for the sham condition. More specifically, sham stimulation yielded improvements in the 3-back task and the Color, Color-Word, and Interference Score of the Stroop Test, an effect likely caused by task practice. Both, iTBS and cTBS, produced improvements in Digits Backward and impairments in 3-back task accuracy. Moreover, iTBS increased Interference Score in the Stroop Test in spite of the improved word reading and impaired color naming, whereas cTBS decreased the time required to complete the Tower of Hanoi. Differing from TBS outcomes reported for cortico-spinal measures on the primary motor cortex, our analyses did not reveal any of the expected performance differences across stimulation protocols. However, if one considers independently pre/post differences for each individual outcome measure and task, either one or both of the active protocols appeared to modulate WM and EF. We critically discuss the value, potential explanations, and some plausible interpretations for this set of subtle impacts of left dlPFC TBS in humans.

Role of the Cerebellum in Adaptation to Delayed Action Effects

Actions are typically associated with sensory consequences. For example, knocking at a door results in predictable sounds. These self-initiated sensory stimuli are known to elicit smaller cortical responses compared to passively presented stimuli, e.g., early auditory evoked magnetic fields known as M100 and M200 components are attenuated. Current models implicate the cerebellum in the prediction of the sensory consequences of our actions. However, causal evidence is largely missing. In this study, we introduced a constant delay (of 100 ms) between actions and action-associated sounds, and we recorded magnetoencephalography (MEG) data as participants adapted to the delay. We found an increase in the attenuation of the M100 component over time for self-generated sounds, which indicates cortical adaptation to the introduced delay. In contrast, no change in M200 attenuation was found. Interestingly, disrupting cerebellar activity via transcranial magnetic stimulation (TMS) abolished the adaptation of M100 attenuation, while the M200 attenuation reverses to an M200 enhancement. Our results provide causal evidence for the involvement of the cerebellum in adapting to delayed action effects, and thus in the prediction of the sensory consequences of our actions.

Repetitive transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex in the treatment of generalized anxiety disorder: A randomized, double-blind sham controlled clinical trial

BACKGROUND

Up to 50% of people with GAD fail to respond to first-line pharmacotherapies for generalized anxiety disorder (GAD), partly due to poor treatment compliance rates and partly due to the complex physiology underlying GAD. Thus, new non-invasive techniques, like repetitive transcranial magnetic stimulation (rTMS) are being investigated.

METHODS

Participants were recruited from two different mood disorder sites: Kingston, Ontario, Canada and Sofia, Bulgaria. Hamilton Anxiety Rating Scale (HARS) scores were reported from patients diagnosed with GAD following treatment with high-frequency (20Hz) rTMS applied to the right dorsal lateral prefrontal cortex (DLPFC).

RESULTS

By the end of 25 rTMS treatments, the ACTIVE (n=15) treatment group showed a clinically significant reduction in the HARS scores compared to the SHAM (n=25) group. Hedge's g at visit 4 (following 25 rTMS treatments) was 2.1 between ACTIVE and SHAM treatments. Furthermore, at 2 and 4weeks follow-up (after the end of treatment) HARS scores of the ACTIVE group remained stable and even slightly improved, demonstrating a sustained effect of the response.

LIMITATIONS

Relatively small sample size of the ACTIVE group as well as the SHAM procedure may limit the generalizability of the results.

CONCLUSIONS

Thus, participants receiving rTMS treatment showed a clinically significant decrease in reported anxiety symptoms as measured by the HARS. rTMS may be a treatment options for patients treatment refractory to pharmacotherapies. www.clinicaltrials.gov: NCT00616447.

[The importance of neuronal networks for motor rehabilitation after a stroke]

Every year in Europe 1.5 million patients suffer a new stroke. Despite the further developments in acute therapy with nationwide stroke units, thrombolysis, thrombectomy and post-acute neurorehabilitation, only a small proportion of patients recover to a satisfactory degree allowing them to return to their normal social and professional life. This makes stroke the main cause of long-term disability with a corresponding impact on patient lives, socioeconomics and the healthcare system. Thus, the concepts of neurorehabilitation have to be extended to enhance the effects of rehabilitative treatment strategies. To achieve this, an understanding of the prediction of the course of recovery, the mechanisms underlying functional recovery and factors influencing recovery have to be enhanced for the development towards patient-tailored precision medicine approaches. A central point towards this is the understanding of stroke as a disease, which not only influences the damaged area but also the associated network. This is crucial for the understanding of the stroke-induced deficits, for prediction of recovery and options for interventional treatment strategies, which can target different areas in this network (e.g. primary motor cortex and secondary motor regions) based on individual factors of the patient. The present article discusses the importance of network alterations for motor neurorehabilitation after a stroke and which novel options, concepts and consequences could arise from this for neurorehabilitation.

Inhibitory rTMS of secondary somatosensory cortex reduces intensity but not pleasantness of gentle touch

Research suggests that the discriminative and affective aspects of touch are processed differently in the brain. Primary somatosensory cortex is strongly implicated in touch discrimination, whereas insular and prefronal regions have been associated with pleasantness aspects of touch. However, the role of secondary somatosensory cortex (S2) is less clear. In the current study we used inhibitory repetitive transcranial magnetic stimulation (rTMS) to temporarily deactivate S2 and probe its role in touch perception. Nineteen healthy adults received two sessions of 1-Hz rTMS on separate days, one targeting right S2 and the other targeting the vertex (control). Before and after rTMS, subjects rated the intensity and pleasantness of slow and fast gentle brushing of the hand and performed a 2-point tactile discrimination task, followed by fMRI during additional brushing. rTMS to S2 (but not vertex) decreased intensity ratings of fast brushing, without altering touch pleasantness or spatial discrimination. MRI showed a reduced response to brushing in S2 (but not in S1 or insula) after S2 rTMS. Together, our results show that reducing touch-evoked activity in S2 decreases perceived touch intensity, suggesting a causal role of S2 in touch intensity perception.