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Lowe CJ, Manocchio F, Safati AB, Hall PA. The effects of theta burst stimulation (TBS) targeting the prefrontal cortex on executive functioning: A systematic review and meta-analysis. Neuropsychologia 2018; 111:344-359. [PMID: 29438672 DOI: 10.1016/j.neuropsychologia.2018.02.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 02/02/2018] [Accepted: 02/03/2018] [Indexed: 12/16/2022]
Abstract
Theta burst stimulation (TBS) is a highly efficient repetitive transcranial magnetic stimulation (rTMS) variant employed in experimental and clinical treatment paradigms. Despite widespread usage of TBS targeting the prefrontal cortex (PFC), there has been no systematic review of the evidence linking TBS protocols to changes in task performance on common measures of prefrontal function in general, and executive functions specifically. A systematic review of the literature was conducted using PsycINFO, PubMed, Web of Science and Scopus databases to identify articles examining the effects of TBS targeting the PFC on executive function task performance. Both the up-regulating (intermittent theta burst stimulation; iTBS) and down-regulating (continuous theta burst stimulation; cTBS) variants of TBS were considered. 32 (29 cTBS; 8 iTBS) studies met the inclusion criteria. Participants (n = 759; 51.41% female) were primarily young adults (Mage = 26), with one study examining the effects of cTBS and iTBS in older adults. Results from individual studies were converted to Hedge's g and random-effects models were used to estimate the overall effect size for each protocol. Age, biological sex, and control methodology were examined as potential moderators of the cTBS effect on executive function test performance. Findings indicated a- reliable attentuating effect of cTBS on executive function task performance (g = -.244, Z = -5.920, p < .001); this effect was relatively uniform across included studies (Q= 24.178, p = .838, I2 = 0). Although no significant moderators of the cTBS effect were identified, laterality sub analyses indicated that the magnitude of the effect was significantly higher (Mdiff = .213, Zdiff = 2.546, p = .011) for left-sided (g = -.358, Z = -5.816, p < .001) relative to right-sided (g = -.145, Z = -2.552, p = .011) PFC stimulation. A systematic review of iTBS studies revealed variability in reliability of effects though most were in the theorized direction. TBS protocols appear to be effective in modulating prefrontal cortical excitability in previously theorized directions.
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Affiliation(s)
- Cassandra J Lowe
- Prevention Neuroscience Lab, School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada N2L 3G1
| | - Felicia Manocchio
- Prevention Neuroscience Lab, School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada N2L 3G1
| | - Adrian B Safati
- Prevention Neuroscience Lab, School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada N2L 3G1
| | - Peter A Hall
- Prevention Neuroscience Lab, School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada N2L 3G1.
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152
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Stimulating the Healthy Brain to Investigate Neural Correlates of Motor Preparation: A Systematic Review. Neural Plast 2018; 2018:5846096. [PMID: 29670648 PMCID: PMC5835236 DOI: 10.1155/2018/5846096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 11/08/2017] [Accepted: 11/22/2017] [Indexed: 12/30/2022] Open
Abstract
Objective Noninvasive brain stimulation techniques can be used to selectively increase or decrease the excitability of a cortical region, providing a unique opportunity to assess the causal contribution of that region to the process being assessed. The objective of this paper is to systematically examine studies investigating changes in reaction time induced by noninvasive brain stimulation in healthy participants during movement preparation. Methods A systematic review of the literature was performed in the PubMed, MEDLINE, EMBASE, PsycINFO, and Web of science databases. A combination of keywords related to motor preparation, associated behavioral outcomes, and noninvasive brain stimulation methods was used. Results Twenty-seven studies were included, and systematic data extraction and quality assessment were performed. Reaction time results were transformed in standardised mean difference and graphically pooled in forest plots depending on the targeted cortical area and the type of stimulation. Conclusions Despite methodological heterogeneity among studies, results support a functional implication of five cortical regions (dorsolateral prefrontal cortex, posterior parietal cortex, supplementary motor area, dorsal premotor cortex, and primary motor cortex), integrated into a frontoparietal network, in various components of motor preparation ranging from attentional to motor aspects.
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153
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Salazar APS, Vaz PG, Marchese RR, Stein C, Pinto C, Pagnussat AS. Noninvasive Brain Stimulation Improves Hemispatial Neglect After Stroke: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil 2018; 99:355-366.e1. [DOI: 10.1016/j.apmr.2017.07.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/13/2017] [Accepted: 07/16/2017] [Indexed: 10/19/2022]
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154
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Heidegger T, Hansen-Goos O, Batlaeva O, Annak O, Ziemann U, Lötsch J. A Data-Driven Approach to Responder Subgroup Identification after Paired Continuous Theta Burst Stimulation. Front Hum Neurosci 2017; 11:382. [PMID: 28824394 PMCID: PMC5543102 DOI: 10.3389/fnhum.2017.00382] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/07/2017] [Indexed: 12/11/2022] Open
Abstract
Background: Modulation of cortical excitability by transcranial magnetic stimulation (TMS) is used for investigating human brain functions. A common observation is the high variability of long-term depression (LTD)-like changes in human (motor) cortex excitability. This study aimed at analyzing the response subgroup distribution after paired continuous theta burst stimulation (cTBS) as a basis for subject selection. Methods: The effects of paired cTBS using 80% active motor threshold (AMT) in 31 healthy volunteers were assessed at the primary motor cortex (M1) corresponding to the representation of the first dorsal interosseous (FDI) muscle of the left hand, before and up to 50 min after plasticity induction. The changes in motor evoked potentials (MEPs) were analyzed using machine-learning derived methods implemented as Gaussian mixture modeling (GMM) and computed ABC analysis. Results: The probability density distribution of the MEP changes from baseline was tri-modal, showing a clear separation at 80.9%. Subjects displaying at least this degree of LTD-like changes were n = 6 responders. By contrast, n = 7 subjects displayed a paradox response with increase in MEP. Reassessment using ABC analysis as alternative approach led to the same n = 6 subjects as a distinct category. Conclusion: Depressive effects of paired cTBS using 80% AMT endure at least 50 min, however, only in a small subgroup of healthy subjects. Hence, plasticity induction by paired cTBS might not reflect a general mechanism in human motor cortex excitability. A mathematically supported criterion is proposed to select responders for enrolment in assessments of human brain functional networks using virtual brain lesions.
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Affiliation(s)
- Tonio Heidegger
- Clinic of Neurology, Goethe-UniversityFrankfurt am Main, Germany
| | - Onno Hansen-Goos
- Institute of Clinical Pharmacology, Goethe-UniversityFrankfurt am Main, Germany
| | - Olga Batlaeva
- Clinic of Neurology, Goethe-UniversityFrankfurt am Main, Germany
| | - Onur Annak
- Institute of Clinical Pharmacology, Goethe-UniversityFrankfurt am Main, Germany
| | - Ulf Ziemann
- Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University TübingenTübingen, Germany
| | - Jörn Lötsch
- Institute of Clinical Pharmacology, Goethe-UniversityFrankfurt am Main, Germany.,Project Group Translational Medicine and Pharmacology TMP, Fraunhofer Institute for Molecular Biology and Applied Ecology IMEFrankfurt am Main, Germany
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155
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Dissanayaka T, Zoghi M, Farrell M, Egan GF, Jaberzadeh S. Does transcranial electrical stimulation enhance corticospinal excitability of the motor cortex in healthy individuals? A systematic review and meta-analysis. Eur J Neurosci 2017; 46:1968-1990. [DOI: 10.1111/ejn.13640] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 07/03/2017] [Accepted: 07/04/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Thusharika Dissanayaka
- Department of Physiotherapy; School of Primary Health Care; Faculty of Medicine; Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
| | - Maryam Zoghi
- Department of Rehabilitation, Nutrition and Sport; School of Allied Health; La Trobe University; Bundoora Victoria Australia
| | - Michael Farrell
- Monash Biomedical Imaging; Monash University; Melbourne Victoria Australia
- Biomedicine Discovery Institute and Department of Medical Imaging and Radiation Sciences; Monash University; Melbourne Victoria Australia
| | - Gary F. Egan
- Monash Biomedical Imaging; Monash University; Melbourne Victoria Australia
| | - Shapour Jaberzadeh
- Department of Physiotherapy; School of Primary Health Care; Faculty of Medicine; Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
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156
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Etkin A. Is the boss watching? Nat Neurosci 2017; 20:1039-1040. [PMID: 28745724 DOI: 10.1038/nn.4603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Amit Etkin
- Department of Psychiatry and Behavioral Sciences and the Stanford Neurosciences Institute, Stanford University, Stanford, California, USA, and with the Veterans Affairs Palo Alto Healthcare System and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, California, USA
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157
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Chung SW, Lewis BP, Rogasch NC, Saeki T, Thomson RH, Hoy KE, Bailey NW, Fitzgerald PB. Demonstration of short-term plasticity in the dorsolateral prefrontal cortex with theta burst stimulation: A TMS-EEG study. Clin Neurophysiol 2017; 128:1117-1126. [DOI: 10.1016/j.clinph.2017.04.005] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/28/2017] [Accepted: 04/04/2017] [Indexed: 12/13/2022]
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158
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Tremblay S, Hannah R, Rawji V, Rothwell JC. Modulation of iTBS after-effects via concurrent directional TDCS: A proof of principle study. Brain Stimul 2017; 10:744-747. [PMID: 28404455 PMCID: PMC5487022 DOI: 10.1016/j.brs.2017.03.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/16/2017] [Accepted: 03/20/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Polarising currents can modulate membrane potentials in animals, affecting the after-effect of theta burst stimulation (TBS) on synaptic strength. OBJECTIVE We examined whether a similar phenomenon could also be observed in human motor cortex (M1) using transcranial direct current stimulation (TDCS) during monophasic intermittent TBS (iTBS). METHODS TDCS was applied during posterior-anterior iTBS using three different conditions: posterior-anterior TDCS (anode 3.5 cm posterior to M1, cathode 3.5 cm anterior to M1), anterior-posterior TDCS (cathode 3.5 cm posterior to M1, anode 3.5 cm anterior to M1), and sham TDCS. RESULTS When the direction of TDCS (posterior-anterior) matched the direction of the electrical field induced by iTBS, we found a 19% non-significant increase in excitability changes in comparison with iTBS combined with sham TDCS. When the TDCS was reversed (anterior-posterior), the excitatory effect of iTBS was abolished. CONCLUSION Our findings suggest that excitatory after-effects of iTBS can be modulated by directionally-specific TDCS.
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Affiliation(s)
- Sara Tremblay
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK.
| | - Ricci Hannah
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
| | - Vishal Rawji
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
| | - John C Rothwell
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
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159
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Shirota Y, Dhaka S, Paulus W, Sommer M. Current direction-dependent modulation of human hand motor function by intermittent theta burst stimulation (iTBS). Neurosci Lett 2017; 650:109-113. [PMID: 28435045 DOI: 10.1016/j.neulet.2017.04.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/08/2017] [Accepted: 04/18/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transcranial magnetic stimulation (TMS) with different current directions can activate different sets of neurons. Current direction can also affect the results of repetitive TMS. OBJECTIVE To test the influence of uni-directional intermittent theta burst stimulation (iTBS) using different current directions, namely posteroanterior (PA) and anteroposterior (AP), on motor behaviour. METHODS In a cross-over design, PA- and AP-iTBS was applied over the left primary motor cortex in 19 healthy, right-handed volunteers. Performance of a finger-tapping task was recorded before and 0, 10, 20, and 30min after the iTBS. The task was conducted with the right and left hands separately at each time point. As a control, AP-iTBS with reduced intensity was applied to 14 participants in a separate session (APweak condition). RESULTS The finger-tapping count with the left hand was decreased after PA-iTBS. Neither AP- nor APweak-iTBS altered the performance. CONCLUSIONS Current direction had a significant impact on the after-effects of iTBS.
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Affiliation(s)
- Yuichiro Shirota
- Department of Clinical Neurophysiology, University Medical Center Göttingen, Göttingen, Germany.
| | - Suman Dhaka
- Department of Clinical Neurophysiology, University Medical Center Göttingen, Göttingen, Germany; Indian Institute of Technology, Guwahati, Assam, India.
| | - Walter Paulus
- Department of Clinical Neurophysiology, University Medical Center Göttingen, Göttingen, Germany.
| | - Martin Sommer
- Department of Clinical Neurophysiology, University Medical Center Göttingen, Göttingen, Germany.
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160
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The effector independent nature of motor imagery: Evidence from rTMS induced inhibition to the primary motor cortices. Neuropsychologia 2017; 97:1-8. [DOI: 10.1016/j.neuropsychologia.2017.01.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/05/2017] [Accepted: 01/20/2017] [Indexed: 01/15/2023]
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161
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Priming theta burst stimulation enhances motor cortex plasticity in young but not old adults. Brain Stimul 2017; 10:298-304. [PMID: 28089653 DOI: 10.1016/j.brs.2017.01.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 01/03/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Primary motor cortex neuroplasticity is reduced in old adults, which may contribute to the motor deficits commonly observed in the elderly. Previous research in young subjects suggests that the neuroplastic response can be enhanced using non-invasive brain stimulation (NIBS), with a larger plastic response observed following priming with both long-term potentiation (LTP) and depression (LTD)-like protocols. However, it is not known if priming stimulation can also modulate plasticity in older adults. OBJECTIVE To investigate if priming NIBS can be used to modulate motor cortical plasticity in old subjects. METHODS In 16 young (22.3 ± 1.0 years) and 16 old (70.2 ± 1.7 years) subjects, we investigated the response to intermittent theta burst stimulation (iTBS; LTP-like) when applied 10 min after sham stimulation, continuous TBS (cTBS; LTD-like) or an identical block of iTBS. Corticospinal plasticity was assessed by recording changes in motor evoked potential (MEP) amplitude. RESULTS In young subjects, priming with cTBS (cTBS + iTBS) resulted in larger MEPs than priming with either iTBS (iTBS + iTBS; P = 0.001) or sham (sham + iTBS; P < 0.0001), while larger MEPs were seen following iTBS + iTBS than sham + iTBS (P < 0.0001). In old subjects, the response to iTBS + iTBS was not different to sham + iTBS (P > 0.9), whereas the response to cTBS + iTBS was reduced relative to iTBS + iTBS (P = 0.02) and sham + iTBS (P = 0.04). CONCLUSIONS Priming TBS is ineffective for modifying M1 plasticity in older adults, which may limit the therapeutic use of priming stimulation in neurological conditions common in the elderly.
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162
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Opie GM, Vosnakis E, Ridding MC, Ziemann U, Semmler JG. WITHDRAWN: Priming theta burst stimulation enhances motor cortex plasticity in young but not old adults. Brain Stimul 2016:S1935-861X(16)30311-4. [PMID: 27888026 DOI: 10.1016/j.brs.2016.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- George M Opie
- Discipline of Physiology, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Eleni Vosnakis
- Discipline of Physiology, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Michael C Ridding
- Robinson Research Institute, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Ulf Ziemann
- Department of Neurology & Stroke, Hertie-Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - John G Semmler
- Discipline of Physiology, Adelaide Medical School, The University of Adelaide, Adelaide, Australia.
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163
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Kubis N. Non-Invasive Brain Stimulation to Enhance Post-Stroke Recovery. Front Neural Circuits 2016; 10:56. [PMID: 27512367 PMCID: PMC4961863 DOI: 10.3389/fncir.2016.00056] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/14/2016] [Indexed: 12/22/2022] Open
Abstract
Brain plasticity after stroke remains poorly understood. Patients may improve spontaneously within the first 3 months and then more slowly in the coming year. The first day, decreased edema and reperfusion of the ischemic penumbra may possibly account for these phenomena, but the improvement during the next weeks suggests plasticity phenomena and cortical reorganization of the brain ischemic areas and of more remote areas. Indeed, the injured ischemic motor cortex has a reduced cortical excitability at the acute phase and a suspension of the topographic representation of affected muscles, whereas the contralateral motor cortex has an increased excitability and an enlarged somatomotor representation; furthermore, contralateral cortex exerts a transcallosal interhemispheric inhibition on the ischemic cortex. This results from the imbalance of the physiological reciprocal interhemispheric inhibition of each hemisphere on the other, contributing to worsening of neurological deficit. Cortical excitability is measurable through transcranial magnetic stimulation (TMS) and prognosis has been established according to the presence of motor evoked potentials (MEP) at the acute phase of stroke, which is predictive of better recovery. Conversely, the lack of response to early stimulation is associated with a poor functional outcome. Non-invasive stimulation techniques such as repetitive TMS (rTMS) or transcranial direct current stimulation (tDCS) have the potential to modulate brain cortical excitability with long lasting effects. In the setting of cerebrovascular disease, around 1000 stroke subjects have been included in placebo-controlled trials so far, most often with an objective of promoting motor recovery of the upper limb. High frequency repetitive stimulation (>3 Hz) rTMS, aiming to increase excitability of the ischemic cortex, or low frequency repetitive stimulation (≤1 Hz), aiming to reduce excitability of the contralateral homonymous cortex, or combined therapies, have shown various effects on the functional disability score and neurological scales of treated patients and on the duration of the treatment. We review here the patients’ characteristics and parameters of stimulation that could predict a good response, as well as safety issues. At last, we review what we have learnt from experimental studies and discuss potential directions to conduct future studies.
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Affiliation(s)
- Nathalie Kubis
- Service de Physiologie Clinique, AP-HP, Hôpital LariboisièreParis, France; Université Paris Diderot, Sorbonne Paris Cité, CART, INSERM U965Paris, France
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164
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Facilitatory non-invasive brain stimulation in older adults: the effect of stimulation type and duration on the induction of motor cortex plasticity. Exp Brain Res 2016; 234:3411-3423. [DOI: 10.1007/s00221-016-4740-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
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165
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De Dreu CKW, Kret ME, Sligte IG. Modulating prefrontal control in humans reveals distinct pathways to competitive success and collective waste. Soc Cogn Affect Neurosci 2016; 11:1236-44. [PMID: 27036875 DOI: 10.1093/scan/nsw045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/28/2016] [Indexed: 11/13/2022] Open
Abstract
Competitive decision making may require controlling and calculative mind-sets. We examined this possibility in repeated predator-prey contests by up- or down-regulating the individual's right inferior frontal gyrus (rIFG), a brain region involved in impulse inhibition and mentalizing. Following brain stimulation, subjects invested as predator or prey against a non-treated antagonist. Relative to sham-treatment (i) prey-defense was relatively frequent, strong and unaffected by stimulation, (ii) down-regulating predator rIFG produced a high-firing strategy-predators earned more because they attacked more frequently, while (iii) up-regulating predator rIFG produced a track-and-attack strategy-predators earned more because they attacked especially when their (non-stimulated) antagonist lowered its prey-defense. Results suggest that calculative mindsets are not needed to compete effectively, especially not when the goal is to survive. Enhanced prefrontal control enables individuals to appear less aggressive without sacrificing competitive effectiveness-it provides human predators with an iron fist in a velvet glove.
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Affiliation(s)
- Carsten K W De Dreu
- Institute of Psychology, Leiden University, PO Box 9555, 2300RB Leiden, The Netherlands Center for Experimental Economics and Political Decision Making (CREED), University of Amsterdam, Roetersstraat 11, 1018WB Amsterdam, The Netherlands
| | - Mariska E Kret
- Institute of Psychology, Leiden University, PO Box 9555, 2300RB Leiden, The Netherlands
| | - Ilja G Sligte
- Department of Psychology, Brain and Cognition, Amsterdam Brain and Cognition Center, University of Amsterdam
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