Noninvasive human brain stimulation

Nonphysiological factors in navigated TMS studies; confounding covariates and valid intracortical estimates

Brain stimulation is used to induce transient alterations of neural excitability to probe or modify brain function. For example, single-pulse transcranial magnetic stimulation (TMS) of the motor cortex can probe corticospinal excitability (CSE). Yet, CSE measurements are confounded by a high level of variability. This variability is due to physical and physiological factors. Navigated TMS (nTMS) systems can record physical parameters of the TMS coil (tilt, location, and orientation) and some also estimate intracortical electric fields (EFs) on a trial-by-trial basis. Thus, these parameters can be partitioned with stepwise regression.

PURPOSE

The primary objective was to dissociate variance due to physical parameters from variance due to physiological factors for CSE estimates. The secondary objective was to establish the predictive validity of EF estimates from spherical head models.

HYPOTHESIS

Variability of physical parameters of TMS predicts CSE variability.

METHODS

Event-related measurements of physical parameters were analyzed in stepwise regression. Partitioned parameter variance and predictive validity were compared for a target-controlled and a nontarget-controlled experiment. A control experiment (preinnervation) confirmed the validity of linear data analysis. A bias-free model quantified the effect of divergence from optimum.

RESULTS

Partitioning physical parameter variance reduces CSE variability. EF estimates from spherical models were valid. Post hoc analyses showed that even small physical fluctuations can confound the statistical comparison of CSE measurements.

CONCLUSIONS

It is necessary to partition physical and physiological variance in TMS studies to make confounded data interpretable. The spatial resolution of nTMS is <5 mm and the EF-estimates are valid.

Frontal eye field, where art thou? Anatomy, function, and non-invasive manipulation of frontal regions involved in eye movements and associated cognitive operations

The planning, control and execution of eye movements in 3D space relies on a distributed system of cortical and subcortical brain regions. Within this network, the Eye Fields have been described in animals as cortical regions in which electrical stimulation is able to trigger eye movements and influence their latency or accuracy. This review focuses on the Frontal Eye Field (FEF) a “hub” region located in Humans in the vicinity of the pre-central sulcus and the dorsal-most portion of the superior frontal sulcus. The straightforward localization of the FEF through electrical stimulation in animals is difficult to translate to the healthy human brain, particularly with non-invasive neuroimaging techniques. Hence, in the first part of this review, we describe attempts made to characterize the anatomical localization of this area in the human brain. The outcome of functional Magnetic Resonance Imaging (fMRI), Magneto-encephalography (MEG) and particularly, non-invasive mapping methods such a Transcranial Magnetic Stimulation (TMS) are described and the variability of FEF localization across individuals and mapping techniques are discussed. In the second part of this review, we will address the role of the FEF. We explore its involvement both in the physiology of fixation, saccade, pursuit, and vergence movements and in associated cognitive processes such as attentional orienting, visual awareness and perceptual modulation. Finally in the third part, we review recent evidence suggesting the high level of malleability and plasticity of these regions and associated networks to non-invasive stimulation. The exploratory, diagnostic, and therapeutic interest of such interventions for the modulation and improvement of perception in 3D space are discussed.

Knowledge is power: how conceptual knowledge transforms visual cognition

In this review, we synthesize the existing literature demonstrating the dynamic interplay between conceptual knowledge and visual perceptual processing. We consider two theoretical frameworks that demonstrate interactions between processes and brain areas traditionally considered perceptual or conceptual. Specifically, we discuss categorical perception, in which visual objects are represented according to category membership, and highlight studies showing that category knowledge can penetrate early stages of visual analysis. We next discuss the embodied account of conceptual knowledge, which holds that concepts are instantiated in the same neural regions required for specific types of perception and action, and discuss the limitations of this framework. We additionally consider studies showing that gaining abstract semantic knowledge about objects and faces leads to behavioral and electrophysiological changes that are indicative of more efficient stimulus processing. Finally, we consider the role that perceiver goals and motivation may play in shaping the interaction between conceptual and perceptual processing. We hope to demonstrate how pervasive such interactions between motivation, conceptual knowledge, and perceptual processing are in our understanding of the visual environment, and to demonstrate the need for future research aimed at understanding how such interactions arise in the brain.

Simultaneous transcranial magnetic stimulation and single-neuron recording in alert non-human primates

Transcranial magnetic stimulation (TMS) is a widely used, noninvasive method for stimulating nervous tissue, yet its mechanisms of effect are poorly understood. Here we report novel methods for studying the influence of TMS on single neurons in the brain of alert non-human primates. We designed a TMS coil that focuses its effect near the tip of a recording electrode and recording electronics that enable direct acquisition of neuronal signals at the site of peak stimulus strength minimally perturbed by stimulation artifact in intact, awake monkeys (Macaca mulatta). We recorded action potentials within ~1 ms after 0.4 ms TMS pulses and observed changes in activity that differed significantly for active stimulation as compared to sham stimulation. The methodology is compatible with standard equipment in primate laboratories, allowing for easy implementation. Application of these new tools will facilitate the refinement of next generation TMS devices, experiments, and treatment protocols.

Non-invasive brain stimulation in neurorehabilitation: local and distant effects for motor recovery

Non-invasive brain stimulation (NIBS) may enhance motor recovery after neurological injury through the causal induction of plasticity processes. Neurological injury, such as stroke, often results in serious long-term physical disabilities, and despite intensive therapy, a large majority of brain injury survivors fail to regain full motor function. Emerging research suggests that NIBS techniques, such as transcranial magnetic (TMS) and direct current (tDCS) stimulation, in association with customarily used neurorehabilitative treatments, may enhance motor recovery. This paper provides a general review on TMS and tDCS paradigms, the mechanisms by which they operate and the stimulation techniques used in neurorehabilitation, specifically stroke. TMS and tDCS influence regional neural activity underlying the stimulation location and also distant interconnected network activity throughout the brain. We discuss recent studies that document NIBS effects on global brain activity measured with various neuroimaging techniques, which help to characterize better strategies for more accurate NIBS stimulation. These rapidly growing areas of inquiry may hold potential for improving the effectiveness of NIBS-based interventions for clinical rehabilitation.

Calculating the induced electromagnetic fields in real human head by deep transcranial magnetic stimulation

Stimulation of deeper brain structures by transcranial magnetic stimulation (TMS) may be beneficial in the treatment of several neurological and psychiatric disorders. This paper presents numerical simulation of deep transcranial magnetic stimulation (dTMS) by considering double cone, H-and Halo coils. Three-dimensional distributions of the induced fields i.e. magnetic flux density, current density and electric fields in realistic head model by dTMS coils were calculated by impedance method and the results were compared with that of figure-of-eight coil. It was found that double cone and H-coils have significantly deep field penetration at the expense of induced higher and wider spread electrical fields in superficial cortical regions. The Halo coil working with a circular coil carrying currents in opposite directions provides a flexible way to stimulate deep brain structures with much lower stimulation in superficial brain tissues.

Facilitating the right but not left DLPFC by TMS decreases truthfulness of object-naming responses

Dorsolateral prefrontal cortex (DLPFC) participates in many mental functions involving cognitive control. This also applies to processes underlying deception. Recently it was shown that, compared to the opposite effect found with left-hemisphere 1-Hz repetitive transcranial magnetic stimulation of the DLPFC, right-hemisphere stimulation decreased the propensity to produce untruthful responses in a subsequent task where subjects had freedom to name presented stimulus-objects either veridically or nonveridically. In a similar experiment, the purpose of the present study was to test whether changing the rTMS protocol from the disrupting to facilitatory type can lead to opposite results. When trains of 10-Hz pulses were delivered to the right DLPFC, propensity to lie increased while similar left-hemisphere DLPFC stimulation did not change the rate of untruthful responses. We can conclude that the way how right DLPFC and other areas functionally associated with it are involved in producing truthful or deliberately deceptive statements about perceived objects considerably depends on what are the parameters of stimulation by which functionality of this system is manipulated.

Hemodynamic responses in rat brain during transcranial direct current stimulation: a functional near-infrared spectroscopy study

In the present study, we monitored hemodynamic responses in rat brains during transcranial direct current stimulation (tDCS) using functional near-infrared spectroscopy (fNIRS). Seven rats received transcranial anodal stimulation with 200 μA direct current (DC) on their right barrel cortex for 10 min. The concentration changes of oxygenated hemoglobin (oxy-Hb) were continuously monitored during stimulation (10 min) and after stimulation (20 min). The trend of hemodynamic response changes was modeled using linear regression, and the relationship between incremental and decremental rates of oxy-Hb was investigated by correlation analysis. Our results showed that the oxy-Hb concentration was almost linearly increased and decreased during and after stimulation, respectively. In addition, a significant negative correlation (p < 0.05) was found between the rate of increase of oxy-Hb during stimulation and the rate of decrease of oxy-Hb after stimulation, indicating that the recovery time after tDCS may not depend on the total amount of hemodynamic changes in the stimulated brain area. Our results also demonstrated considerable individual variability in the rate of change of hemodynamic responses even with the same direct current dose to identical brain regions. This suggests that individual differences in tDCS after-effects may originate from intrinsic differences in the speed of DC stimulation "uptake" rather than differences in the total capacity of DC uptake, and thus the stimulation parameters may need to be customized for each individual in order to maximize tDCS after-effects.

Transcranial magnetic stimulation (TMS)/repetitive TMS in mild cognitive impairment and Alzheimer's disease

Several Transcranial Magnetic Stimulation (TMS) techniques can be applied to noninvasively measure cortical excitability and brain plasticity in humans. TMS has been used to assess neuroplastic changes in Alzheimer's disease (AD), corroborating findings that cortical physiology is altered in AD due to the underlying neurodegenerative process. In fact, many TMS studies have provided physiological evidence of abnormalities in cortical excitability, connectivity, and plasticity in patients with AD. Moreover, the combination of TMS with other neurophysiological techniques, such as high-density electroencephalography (EEG), makes it possible to study local and network cortical plasticity directly. Interestingly, several TMS studies revealed abnormalities in patients with early AD and even with mild cognitive impairment (MCI), thus enabling early identification of subjects in whom the cholinergic degeneration has occurred. Furthermore, TMS can influence brain function if delivered repetitively; repetitive TMS (rTMS) is capable of modulating cortical excitability and inducing long-lasting neuroplastic changes. Preliminary findings have suggested that rTMS can enhance performances on several cognitive functions impaired in AD and MCI. However, further well-controlled studies with appropriate methodology in larger patient cohorts are needed to replicate and extend the initial findings. The purpose of this paper was to provide an updated and comprehensive systematic review of the studies that have employed TMS/rTMS in patients with MCI and AD.

Neuronal spike initiation modulated by extracellular electric fields

Based on a reduced two-compartment model, the dynamical and biophysical mechanism underlying the spike initiation of the neuron to extracellular electric fields is investigated in this paper. With stability and phase plane analysis, we first investigate in detail the dynamical properties of neuronal spike initiation induced by geometric parameter and internal coupling conductance. The geometric parameter is the ratio between soma area and total membrane area, which describes the proportion of area occupied by somatic chamber. It is found that varying it could qualitatively alter the bifurcation structures of equilibrium as well as neuronal phase portraits, which remain unchanged when varying internal coupling conductance. By analyzing the activating properties of somatic membrane currents at subthreshold potentials, we explore the relevant biophysical basis of spike initiation dynamics induced by these two parameters. It is observed that increasing geometric parameter could greatly decrease the intensity of the internal current flowing from soma to dendrite, which switches spike initiation dynamics from Hopf bifurcation to SNIC bifurcation; increasing internal coupling conductance could lead to the increase of this outward internal current, whereas the increasing range is so small that it could not qualitatively alter the spike initiation dynamics. These results highlight that neuronal geometric parameter is a crucial factor in determining the spike initiation dynamics to electric fields. The finding is useful to interpret the functional significance of neuronal biophysical properties in their encoding dynamics, which could contribute to uncovering how neuron encodes electric field signals.

A comparison of the effects of transcranial direct current stimulation and caffeine on vigilance and cognitive performance during extended wakefulness

BACKGROUND

Sleep deprivation from extended duty hours is a common complaint for many occupations. Caffeine is one of the most common countermeasures used to combat fatigue. However, the benefits of caffeine decline over time and with chronic use.

OBJECTIVE

Our objective was to evaluate the efficacy of anodal transcranial direct current stimulation (tDCS) applied to the pre-frontal cortex at 2 mA for 30 min to remediate the effects of sleep deprivation and to compare the behavioral effects of tDCS with those of caffeine.

METHODS

Three groups of 10 participants each received either active tDCS with placebo gum, caffeine gum with sham tDCS, or sham tDCS with placebo gum during 30 h of extended wakefulness.

RESULTS

Our results show that tDCS prevented a decrement in vigilance and led to better subjective ratings for fatigue, drowsiness, energy, and composite mood compared to caffeine and control in sleep-deprived individuals. Both the tDCS and caffeine produced similar improvements in latencies on a short-term memory task and faster reaction times in a psychomotor task when compared to the placebo group. Interestingly, changes in accuracy for the tDCS group were not correlated to changes in mood; whereas, there was a relationship for the caffeine and sham groups.

CONCLUSION

Our data suggest that tDCS could be a useful fatigue countermeasure and may be more beneficial than caffeine since boosts in performance and mood last several hours.

Brain stimulation in migraine

Migraine is a very prevalent disease with great individual disability and socioeconomic burden. Despite intensive research effort in recent years, the etiopathogenesis of the disease remains to be elucidated. Recently, much importance has been given to mechanisms underlying the cortical excitability that has been suggested to be dysfunctional in migraine. In recent years, noninvasive brain stimulation techniques based on magnetic fields (transcranial magnetic stimulation, TMS) and on direct electrical currents (transcranial direct current stimulation, tDCS) have been shown to be safe and effective tools to explore the issue of cortical excitability, activation, and plasticity in migraine. Moreover, TMS, repetitive TMS (rTMS), and tDCS, thanks to their ability to interfere with and/or modulate cortical activity inducing plastic, persistent effects, have been also explored as potential therapeutic approaches, opening an interesting perspective for noninvasive neurostimulation for both symptomatic and preventive treatment of migraine and other types of headache. In this chapter we critically review evidence regarding the role of noninvasive brain stimulation in the pathophysiology and treatment of migraine, delineating the advantages and limits of these techniques together with potential development and future application.

Deep brain stimulation in persistent vegetative States: ethical issues governing decision making

The aim of the present paper was to investigate the fundamental ethical issues of Deep Brain Stimulation (DBS) on patients remaining in Persistent Vegetative State (PVS). First, the purpose of this analysis was to discuss the nature of this intervention in order to classify it such as an ordinary clinical practice, or otherwise as an extraordinary clinical practice or as experimental research. Second, ethical issues, criticisms, and methodological issues of this intervention, also in the future perspectives, are discussed, attempting to identify who could give informed consent for a patient in PVS.

Combotherapy and current concepts as well as future strategies for the treatment of Alzheimer's disease

It has been estimated that 35.6 million people globally had dementia in 2010 and the prevalence of dementia has been predicted to double every 20 years. Thus, 115.4 million people may be living with dementia in 2050. Alzheimer's disease (AD) is the leading cause of dementia and is present in 60%-70% of people with dementia. Unfortunately, there are few approved drugs that can alleviate the cognitive or behavioral symptoms of AD dementia. Recent studies have revealed that pathophysiological changes related to AD occur decades before the appearance of clinical symptoms of dementia. This extended preclinical phase of AD provides a critical chance for disease-modifying agents to halt or delay the relentless process of AD. Although several trials targeting various pathological processes are ongoing, the examination of the combined use of different approaches to combat AD seems warranted. In this article, we will review current therapies, future strategies, and ongoing clinical trials for the treatment of AD with a special focus on combination therapies. Furthermore, preventive strategies for cognitively normal subjects in the presymptomatic stages of AD will also be addressed. In this review, we discuss current hypotheses of the disease process. In the decades since the approval of cholinesterase inhibitors, no new drug has ultimately demonstrated clear success in clinical trials. Given the difficulties that have been encountered in attempts to identify a single drug that can treat AD, we must pursue effective multi-target strategies, ie, combination therapies. The combination of cholinesterase inhibitors and memantine is considered well tolerated and safe, and this combination benefits patients with moderate-to-severe AD. In contrast, with the exception of adjuvant therapies of conventional drugs, combinations of different disease-modifying agents with different mechanisms may have promising synergic effects and benefit cognition, behavior, and daily living function.

[Fundamentals and Clinical Applications of Transcranial Magnetic Stimulation in Neuropsychiatry]

Transcranial Magnetic Stimulation (TMS) is a non-invasive method for stimulation of brain that is based on the ability of a generated magnetic field to penetrate skull and brain meninges, inducing an electric current in the brain tissues that produces neuronal depolarization. TMS can be applied as single pulse of stimulation, pairs of stimuli separated by variable intervals to the same or different brain areas, or as trains of repetitive stimuli at various frequencies. Its mechanism of action is currently unknown. Repetitive TMS can modify the excitability of the cerebral cortex, and has been postulated as a diagnostic and therapeutic tool in the area of neuropsychiatry. The aim of this article is to review the knowledge of the TMS as regards its basic principles, pathophysiological mechanism, and its usefulness in clinical practice.

Preliminary evidence for performance enhancement following parietal lobe stimulation in Developmental Dyscalculia

Nearly 7% of the population exhibit difficulties in dealing with numbers and performing arithmetic, a condition named Developmental Dyscalculia (DD), which significantly affects the educational and professional outcomes of these individuals, as it often persists into adulthood. Research has mainly focused on behavioral rehabilitation, while little is known about performance changes and neuroplasticity induced by the concurrent application of brain-behavioral approaches. It has been shown that numerical proficiency can be enhanced by applying a small-yet constant-current through the brain, a non-invasive technique named transcranial electrical stimulation (tES). Here we combined a numerical learning paradigm with transcranial direct current stimulation (tDCS) in two adults with DD to assess the potential benefits of this methodology to remediate their numerical difficulties. Subjects learned to associate artificial symbols to numerical quantities within the context of a trial and error paradigm, while tDCS was applied to the posterior parietal cortex (PPC). The first subject (DD1) received anodal stimulation to the right PPC and cathodal stimulation to the left PPC, which has been associated with numerical performance's improvements in healthy subjects. The second subject (DD2) received anodal stimulation to the left PPC and cathodal stimulation to the right PPC, which has been shown to impair numerical performance in healthy subjects. We examined two indices of numerical proficiency: (i) automaticity of number processing; and (ii) mapping of numbers onto space. Our results are opposite to previous findings with non-dyscalculic subjects. Only anodal stimulation to the left PPC improved both indices of numerical proficiency. These initial results represent an important step to inform the rehabilitation of developmental learning disabilities, and have relevant applications for basic and applied research in cognitive neuroscience, rehabilitation, and education.

Targeting chronic recurrent low back pain from the top-down and the bottom-up: a combined transcranial direct current stimulation and peripheral electrical stimulation intervention

BACKGROUND

Mechanisms such as neural sensitization and maladaptive cortical organization provide novel targets for therapy in chronic recurrent low back pain (CLBP).

OBJECTIVE

We investigated the effect of a transcranial direct current stimulation (tDCS) and peripheral electrical stimulation (PES) treatment on pain, cortical organization, sensitization and sensory function in CLBP.

METHODS

Using a placebo-controlled crossover design, 16 individuals received four treatments in separate sessions: (i) anodal tDCS/PES; (ii) anodal tDCS/sham PES; (iii) sham tDCS/PES; or (iv) sham tDCS/sham PES. Pain was assessed at baseline, immediately following, and at 1 and 3 days after treatment. Motor cortical organization, sensitization and sensory function were measured before and immediately after treatment.

RESULTS

Combined tDCS/PES reduced pain and sensitization, normalized motor cortical organization and improved sensory function. The reduction in pain was greater in individuals with more pronounced sensitization. Applied alone, tDCS or PES also reduced pain. However, with the exception of improved sensory function and reduced map volume following PES, clinical and neurophysiological outcomes were unaltered by tDCS or PES applied separately. No changes were observed following sham treatment.

CONCLUSION

Our data suggest a combined tDCS/PES intervention more effectively improves CLBP symptoms and mechanisms of cortical organization and sensitization, than either intervention applied alone or a sham control.

rTMS in the treatment of drug addiction: an update about human studies

Drug addiction can be a devastating and chronic relapsing disorder with social, psychological, and physical consequences, and more effective treatment options are needed. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique that has been assessed in a growing number of studies for its therapeutic potential in treating addiction. This review paper offers an overview on the current state of clinical research in treating drug addiction with rTMS. Because of the limited research in this area, all studies (including case reports) that evaluated the therapeutic use of rTMS in nicotine, alcohol, or illicit drug addiction were included in this review. Papers published prior to December 2012 were found through an NCBI PubMed search. A total of eleven studies were identified that met review criteria. There is nascent evidence that rTMS could be effective in reducing cocaine craving and nicotine and alcohol craving and consumption and might represent a potential therapeutic tool for treating addiction. Further studies are needed to identify the optimal parameters of stimulation for the most effective treatment of drug addiction, to improve our comprehension of the treatment neurophysiological effects, and to conduct rigorous, controlled efficacy studies with adequate power.

Task-dependent activity and connectivity predict episodic memory network-based responses to brain stimulation in healthy aging

BACKGROUND

Transcranial magnetic stimulation (TMS) can affect episodic memory, one of the main cognitive hallmarks of aging, but the mechanisms of action remain unclear.

OBJECTIVES

To evaluate the behavioral and functional impact of excitatory TMS in a group of healthy elders.

METHODS

We applied a paradigm of repetitive TMS - intermittent theta-burst stimulation - over left inferior frontal gyrus in healthy elders (n = 24) and evaluated its impact on the performance of an episodic memory task with two levels of processing and the associated brain activity as captured by a pre and post fMRI scans.

RESULTS

In the post-TMS fMRI we found TMS-related activity increases in left prefrontal and cerebellum-occipital areas specifically during deep encoding but not during shallow encoding or at rest. Furthermore, we found a task-dependent change in connectivity during the encoding task between cerebellum-occipital areas and the TMS-targeted left inferior frontal region. This connectivity change correlated with the TMS effects over brain networks.

CONCLUSIONS

The results suggest that the aged brain responds to brain stimulation in a state-dependent manner as engaged by different tasks components and that TMS effect is related to inter-individual connectivity changes measures. These findings reveal fundamental insights into brain network dynamics in aging and the capacity to probe them with combined behavioral and stimulation approaches.

Modelling of deep transcranial magnetic stimulation: different coil configurations

This paper provides a characterization of the induced electric field distributions in the brain of a realistic human model due to 16 different coil configurations. We used the scalar potential finite element method to calculate the induced electric field distributions differentiating the brain structures, e.g. cortex, white matter, cerebellum, thalamus, hypothalamus, hippocampus, pons and midbrain. We found that, despite the presence of a depth-focality tradeoff, some configurations are able to reach subcortical white matter tracts at effective electric field level.

Invasive and non-invasive brain stimulation for treatment of neuropathic pain in patients with spinal cord injury: a review

CONTEXT

Past evidence has shown that invasive and non-invasive brain stimulation may be effective for relieving central pain.

OBJECTIVE

To perform a topical review of the literature on brain neurostimulation techniques in patients with chronic neuropathic pain due to traumatic spinal cord injury (SCI) and to assess the current evidence for their therapeutic efficacy.

METHODS

A MEDLINE search was performed using following terms: "Spinal cord injury", "Neuropathic pain", "Brain stimulation", "Deep brain stimulation" (DBS), "Motor cortex stimulation" (MCS), "Transcranial magnetic stimulation" (TMS), "Transcranial direct current stimulation" (tDCS), "Cranial electrotherapy stimulation" (CES).

RESULTS

Invasive neurostimulation therapies, in particular DBS and epidural MCS, have shown promise as treatments for neuropathic and phantom limb pain. However, the long-term efficacy of DBS is low, while MCS has a relatively higher potential with lesser complications that DBS. Among the non-invasive techniques, there is accumulating evidence that repetitive TMS can produce analgesic effects in healthy subjects undergoing laboratory-induced pain and in chronic pain conditions of various etiologies, at least partially and transiently. Another very safe technique of non-invasive brain stimulation - tDCS - applied over the sensory-motor cortex has been reported to decrease pain sensation and increase pain threshold in healthy subjects. CES has also proved to be effective in managing some types of pain, including neuropathic pain in subjects with SCI.

CONCLUSION

A number of studies have begun to use non-invasive neuromodulatory techniques therapeutically to relieve neuropathic pain and phantom phenomena in patients with SCI. However, further studies are warranted to corroborate the early findings and confirm different targets and stimulation paradigms. The utility of these protocols in combination with pharmacological approaches should also be explored.

Speed of processing in the primary motor cortex: a continuous theta burst stimulation study

'Temporally urgent' reactions are extremely rapid, spatially precise movements that are evoked following discrete stimuli. The involvement of primary motor cortex (M1) and its relationship to stimulus intensity in such reactions is not well understood. Continuous theta burst stimulation (cTBS) suppresses focal regions of the cortex and can assess the involvement of motor cortex in speed of processing. The primary objective of this study was to explore the involvement of M1 in speed of processing with respect to stimulus intensity. Thirteen healthy young adults participated in this experiment. Behavioral testing consisted of a simple button press using the index finger following median nerve stimulation of the opposite limb, at either high or low stimulus intensity. Reaction time was measured by the onset of electromyographic activity from the first dorsal interosseous (FDI) muscle of each limb. Participants completed a 30 min bout of behavioral testing prior to, and 15 min following, the delivery of cTBS to the motor cortical representation of the right FDI. The effect of cTBS on motor cortex was measured by recording the average of 30 motor evoked potentials (MEPs) just prior to, and 5 min following, cTBS. Paired t-tests revealed that, of thirteen participants, five demonstrated a significant attenuation, three demonstrated a significant facilitation and five demonstrated no significant change in MEP amplitude following cTBS. Of the group that demonstrated attenuated MEPs, there was a biologically significant interaction between stimulus intensity and effect of cTBS on reaction time and amplitude of muscle activation. This study demonstrates the variability of potential outcomes associated with the use of cTBS and further study on the mechanisms that underscore the methodology is required. Importantly, changes in motor cortical excitability may be an important determinant of speed of processing following high intensity stimulation.

Enhanced motor learning following task-concurrent dual transcranial direct current stimulation

OBJECTIVE

Transcranial direct current stimulation (tDCS) of the primary motor cortex (M1) has beneficial effects on motor performance and motor learning in healthy subjects and is emerging as a promising tool for motor neurorehabilitation. Applying tDCS concurrently with a motor task has recently been found to be more effective than applying stimulation before the motor task. This study extends this finding to examine whether such task-concurrent stimulation further enhances motor learning on a dual M1 montage.

METHOD

Twenty healthy, right-handed subjects received anodal tDCS to the right M1, dual tDCS (anodal current over right M1 and cathodal over left M1) and sham tDCS in a repeated-measures design. Stimulation was applied for 10 mins at 1.5 mA during an explicit motor learning task. Response times (RT) and accuracy were measured at baseline, during, directly after and 15 mins after stimulation. Motor cortical excitability was recorded from both hemispheres before and after stimulation using single-pulse transcranial magnetic stimulation.

RESULTS

Task-concurrent stimulation with a dual M1 montage significantly reduced RTs by 23% as early as with the onset of stimulation (p<0.01) with this effect increasing to 30% at the final measurement. Polarity-specific changes in cortical excitability were observed with MEPs significantly reduced by 12% in the left M1 and increased by 69% in the right M1.

CONCLUSION

Performance improvement occurred earliest in the dual M1 condition with a stable and lasting effect. Unilateral anodal stimulation resulted only in trendwise improvement when compared to sham. Therefore, task-concurrent dual M1 stimulation is most suited for obtaining the desired neuromodulatory effects of tDCS in explicit motor learning.

Effects of extremely low-frequency magnetic fields on the response of a conductance-based neuron model

To provide insights into the modulation of neuronal activity by extremely low-frequency (ELF) magnetic field (MF), we present a conductance-based neuron model and introduce ELF sinusoidal MF as an additive voltage input. By analyzing spike times and spiking frequency, it is observed that neuron with distinct spiking patterns exhibits different response properties in the presence of MF exposure. For tonic spiking neuron, the perturbations of MF exposure on spike times is maximized at the harmonics of neuronal intrinsic spiking frequency, while it is maximized at the harmonics of bursting frequency for burst spiking neuron. As MF intensity increases, the perturbations also increase. Compared with tonic spiking, bursting dynamics are less sensitive to the perturbations of ELF MF exposure. Further, ELF MF exposure is more prone to perturb neuronal spike times relative to spiking frequency. Our finding suggests that the resonance may be one of the neural mechanisms underlying the modulatory effects of the low-intensity ELF MFs on neuronal activities. The results highlight the impacts of ELF MFs exposure on neuronal activity from the single cell level, and demonstrate various factors including ELF MF properties and neuronal spiking characteristics could determine the outcome of exposure. These insights into the mechanism of MF exposure may be relevant for the design of multi-intensity magnetic stimulus protocols, and may even contribute to the interpretation of MF effects on the central nervous systems.

Differentiation of motor cortical representation of hand muscles by navigated mapping of optimal TMS current directions in healthy subjects

The precision of navigated transcranial magnetic stimulation (TMS) to map the human primary motor cortex may be effected by the direction of TMS-induced current in the brain as determined by the orientation of the stimulation coil. In this study, the authors investigated the effect of current directionality on motor output mapping using navigated brain stimulation. The goal of this study was to determine the optimal coil orientation (and, thus, induced brain current) to activate hand musculature representations relative to each subject's unique neuroanatomical landmarks. The authors studied motor output maps for the first dorsal interosseous, abductor pollicis brevis, and abductor digiti minimi muscles in 10 normal volunteers. Monopolar current pulses were delivered through a figure-of-eight-shaped TMS coil, and motor evoked potentials were recorded using electromyography. At each targeted brain region, the authors systematically rotated the TMS coil to determine the direction of induced current in the brain for induction of the largest motor evoked potentials. These optimal current directions were expressed as an angle relative to each subject's central sulcus. Consistency of the optimal current direction was assessed by repeating the entire mapping procedure on two different occasions across subjects. The authors demonstrate that systematic optimization of current direction as guided by MRI-based neuronavigation improves the resolution of cortical output motor mapping with TMS.

Gone in a flash: manipulation of audiovisual temporal integration using transcranial magnetic stimulation

While converging evidence implicates the right inferior parietal lobule in audiovisual integration, its role has not been fully elucidated by direct manipulation of cortical activity. Replicating and extending an experiment initially reported by Kamke et al. (2012), we employed the sound-induced flash illusion, in which a single visual flash, when accompanied by two auditory tones, is misperceived as multiple flashes (Wilson, 1987; Shams et al., 2000). Slow repetitive (1 Hz) TMS administered to the right angular gyrus, but not the right supramarginal gyrus, induced a transient decrease in the Peak Perceived Flashes (PPF), reflecting reduced susceptibility to the illusion. This finding independently confirms that perturbation of networks involved in multisensory integration can result in a more veridical representation of asynchronous auditory and visual events and that cross-modal integration is an active process in which the objective is the identification of a meaningful constellation of inputs, at times at the expense of accuracy.

Effects of electroconvulsive therapy stimulus pulsewidth and amplitude computed with an anatomically-realistic head model

The efficacy and cognitive outcomes of electro-convulsive therapy (ECT) on psychiatric disorders have been shown to depend on variations in treatment technique. In order to investigate this, a high resolution finite element human head model was generated from MRI scans and implemented with tissue heterogeneity and an excitable ionic neural formulations in the brain. The model was used to compare the effects of altered ECT stimulus amplitude and pulse width on the spatial extent of directly activated brain regions. The results showed that decreases in both amplitude and pulse width could effectively lead to reductions in the size of activated brain regions.

Quantifying uncertainty in Transcranial Magnetic Stimulation - A high resolution simulation study in ICBM space

Transcranial Magnetic Stimulation offers enormous potential for noninvasive brain stimulation. While it is known that brain tissue significantly "reshapes" induced field and charge distributions, most modeling investigations to-date have focused on single-subject data with limited generality. Further, the effects of the significant uncertainties which exist in the simulation (i.e. brain conductivity distributions) and stimulation (e.g. coil positioning and orientations) setup have not been quantified. In this study, we construct a high-resolution anisotropic head model in standard ICBM space, which can be used as a population-representative standard for bioelectromagnetic simulations. Further, we employ Monte-Carlo simulations in order to quantify how uncertainties in conductivity values propagate all the way to induced field and currents, demonstrating significant, regionally dependent dispersions in values which are commonly assumed "ground truth". This framework can be leveraged in order to quantify the effect of any type of uncertainty in noninvasive brain stimulation and bears relevance in all applications of TMS, both investigative and therapeutic.

Electroencephalographic changes following direct current deep brain stimulation of auditory cortex: a new model for investigating neuromodulation

BACKGROUND

Although deep brain (DBS) and transcranial direct current stimulation (tDCS) are used as investigative tools and therapies for a variety of neurological and psychiatric conditions, their mechanisms of action remain poorly understood. Therefore, there is a need for new animal models of neuromodulation.

OBJECTIVE

To introduce and validate a direct current DBS (DC-DBS) model that will use the anatomic precision of intracranial electrodes, as used in DBS, to apply direct current, as used in tDCS, over primary auditory cortex (A1) and induce electroencephalographic (EEG) changes.

METHODS

Twenty-four mice were assigned to 1 of 2 stimulation groups or a sham group and were implanted with electrodes in A1. Stimulation groups underwent DC-DBS stimulation for 20 minutes at 20 μA. Auditory EEG was recorded before stimulation and at 1 hour, 1 week, and 2 weeks poststimulation. EEG was analyzed for changes in N1 (N100 in humans, N40 in mice) amplitude and latency as well as delta and theta power.

RESULTS

DC-DBS led to significant EEG changes (all P values < .05). Among the stimulated animals, there were durable reductions in delta and theta power. There were no differences within the sham group, and neither N40 latencies nor amplitudes changed across time.

CONCLUSION

Our results show DC-DBS-induced reductions in slow-wave activity consistent with recent tDCS studies. We propose that this model will provide a means to explore basic mechanisms of neuromodulation and could facilitate future application of DC-DBS in humans.

Impact of brain tissue filtering on neurostimulation fields: a modeling study

Electrical neurostimulation techniques, such as deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS), are increasingly used in the neurosciences, e.g., for studying brain function, and for neurotherapeutics, e.g., for treating depression, epilepsy, and Parkinson's disease. The characterization of electrical properties of brain tissue has guided our fundamental understanding and application of these methods, from electrophysiologic theory to clinical dosing-metrics. Nonetheless, prior computational models have primarily relied on ex-vivo impedance measurements. We recorded the in-vivo impedances of brain tissues during neurosurgical procedures and used these results to construct MRI guided computational models of TMS and DBS neurostimulatory fields and conductance-based models of neurons exposed to stimulation. We demonstrated that tissues carry neurostimulation currents through frequency dependent resistive and capacitive properties not typically accounted for by past neurostimulation modeling work. We show that these fundamental brain tissue properties can have significant effects on the neurostimulatory-fields (capacitive and resistive current composition and spatial/temporal dynamics) and neural responses (stimulation threshold, ionic currents, and membrane dynamics). These findings highlight the importance of tissue impedance properties on neurostimulation and impact our understanding of the biological mechanisms and technological potential of neurostimulatory methods.

Excitability modulation of the motor system induced by transcranial direct current stimulation: a multimodal approach

Anodal and cathodal transcranial direct current stimulations (tDCS) are both established techniques to induce cortical excitability changes. Typically, in the human motor system, such cortical modulations are inferred through changes in the amplitude of the motor evoked potentials (MEPs). However, it is now possible to directly evaluate tDCS-induced changes at the cortical level by recording the transcranial magnetic stimulation evoked potentials (TEPs) using electroencephalography (EEG). The present study investigated the modulation induced by the tDCS on the motor system. The study evaluates changes in the MEPs, in the amplitude and distribution of the TEPs, in resting state oscillatory brain activity and in behavioral performance in a simple manual response task. Both the short- and long-term tDCS effects were investigated by evaluating their time course at ~0 and 30min after tDCS. Anodal tDCS over the left primary motor cortex (M1) induced an enhancement of corticospinal excitability, whereas cathodal stimulation produced a reduction. These changes in excitability were indexed by changes in MEP amplitude. More interestingly, tDCS modulated the cortical reactivity, which is the neuronal activity evoked by TMS, in a polarity-dependent and site-specific manner. Cortical reactivity increased after anodal stimulation over the left M1, whereas it decreased with cathodal stimulation. These effects were partially present also at long term evaluation. No polarity-specific effect was found either on behavioral measures or on oscillatory brain activity. The latter showed a general increase in the power density of low frequency oscillations (theta and alpha) at both stimulation polarities. Our results suggest that tDCS is able to modulate motor cortical reactivity in a polarity-specific manner, inducing a complex pattern of direct and indirect cortical activations or inhibitions of the motor system-related network, which might be related to changes in synaptic efficacy of the motor cortex.

Magnetic Fields in Noninvasive Brain Stimulation

The idea that magnetic fields could be used therapeutically arose 2000 years ago. These therapeutic possibilities were expanded after the discovery of electromagnetic induction by the Englishman Michael Faraday and the American Joseph Henry. In 1896, Arsène d’Arsonval reported his experience with noninvasive brain magnetic stimulation to the scientific French community. In the second half of the 20th century, changing magnetic fields emerged as a noninvasive tool to study the nervous system and to modulate neural function. In 1985, Barker, Jalinous, and Freeston presented transcranial magnetic stimulation, a relatively focal and painless technique. Transcranial magnetic stimulation has been proposed as a clinical neurophysiology tool and as a potential adjuvant treatment for psychiatric and neurologic conditions. This article aims to contextualize the progress of use of magnetic fields in the history of neuroscience and medical sciences, until 1985.

Ethics of the electrified mind: defining issues and perspectives on the principled use of brain stimulation in medical research and clinical care

In recent years, non-pharmacologic approaches to modifying human neural activity have gained increasing attention. One of these approaches is brain stimulation, which involves either the direct application of electrical current to structures in the nervous system or the indirect application of current by means of electromagnetic induction. Interventions that manipulate the brain have generally been regarded as having both the potential to alleviate devastating brain-related conditions and the capacity to create unforeseen and unwanted consequences. Hence, although brain stimulation techniques offer considerable benefits to society, they also raise a number of ethical concerns. In this paper we will address various dilemmas related to brain stimulation in the context of clinical practice and biomedical research. We will survey current work involving deep brain stimulation, transcranial magnetic stimulation and transcranial direct current stimulation. We will reflect upon relevant similarities and differences between them, and consider some potentially problematic issues that may arise within the framework of established principles of medical ethics: nonmaleficence and beneficence, autonomy, and justice.

Targeted therapies using electrical and magnetic neural stimulation for the treatment of chronic pain in spinal cord injury

BACKGROUND

Chronic neuropathic pain is one of the most common and disabling symptoms in individuals with spinal cord injury (SCI). Over two-thirds of subjects with SCI suffer from chronic pain influencing quality of life, rehabilitation, and recovery. Given the refractoriness of chronic pain to most pharmacological treatments, the majority of individuals with SCI report worsening of this condition over time. Moreover, only 4-6% of patients in this cohort report improvement. Novel treatments targeting mechanisms associated with pain-maladaptive plasticity, such as electromagnetic neural stimulation, may be desirable to improve outcomes. To date, few, small clinical trials have assessed the effects of invasive and noninvasive nervous system stimulation on pain after SCI.

OBJECTIVE

We aimed to review initial efficacy, safety and potential predictors of response by assessing the effects of neural stimulation techniques to treat SCI pain.

SEARCH STRATEGY

A literature search was performed using the PubMed database including studies using the following targeted stimulation strategies: transcranial Direct Current Stimulation (tDCS), High Definition tDCS (HD-tDCS), repetitive Transcranial Magnetical Stimulation (rTMS), Cranial Electrotherapy Stimulation (CES), Transcutaneous Electrical Nerve Stimulation (TENS), Spinal Cord Stimulation (SCS) and Motor Cortex Stimulation (MCS), published prior to June of 2012. We included studies from 1998 to 2012.

RESULTS

Eight clinical trials and one naturalistic observational study (nine studies in total) met the inclusion criteria. Among the clinical trials, three studies assessed the effects of tDCS, two of CES, two of rTMS and one of TENS. The naturalistic study investigated the analgesic effects of SCS. No clinical trials for epidural motor cortex stimulation (MCS) or HD-tDCS were found. Parameters of stimulation and also clinical characteristics varied significantly across studies. Three out of eight studies showed larger effects sizes (0.73, 0.88 and 1.86 respectively) for pain reduction. Classical neuropathic pain symptoms such as dysesthesia (defined as an unpleasant burning sensation in response to touch), allodynia (pain due to a non-painful stimulus), pain in paroxysms, location of SCI in thoracic and lumbar segments and pain in the lower limbs seem to be associated with a positive response to neural stimulation. No significant adverse effects were reported in these studies.

CONCLUSIONS

Chronic pain in SCI is disabling and resistant to common pharmacologic approaches. Electrical and magnetic neural stimulation techniques have been developed to offer a potential tool in the management of these patients. Although some of these techniques are associated with large standardized mean differences to reduce pain, we found an important variability in these results across studies. There is a clear need for the development of methods to decrease treatment variability and increase response to neural stimulation for pain treatment. We discuss potential methods such as neuroimaging or EEG-guided neural stimulation and the development of better surrogate markers of response such as TMS-indexed cortical plasticity.

Fronto-tectal white matter connectivity mediates facilitatory effects of non-invasive neurostimulation on visual detection

The causal ability of pre-target FEF activity to modulate visual detection for perithreshold stimuli has been recently demonstrated in humans by means of non-invasive neurostimulation. Yet in spite of the network-distributed effects of these type of techniques, the white matter (WM) tracts and distant visual nodes contributing to such behavioral impact remain unknown. We hereby used individual data from a group of healthy human subjects, who received time-locked pulses of active or sham Transcranial Magnetic Stimulation (TMS) to the right Frontal Eye Field (FEF) region, and experienced increases in visual detection sensitivity. We then studied the extent to which interindividual differences in visual modulation might be dependent on the WM patterns linking the targeted area to other regions relevant for visuo-attentional behaviors. We report a statistically significant correlation between the probability of connection in a right fronto-tectal pathway (FEF-Superior Colliculus) and the modulation of visual sensitivity during a detection task. Our findings support the potential contribution of this pathway and the superior colliculus in the mediation of visual performance from frontal regions in humans. Furthermore, we also show the ability of a TMS/DTI correlational approach to contribute to the disambiguation of the specific long-range pathways driving network-wide neurostimulatory effects on behavior, anticipating their future role in guiding a more efficient use of focal neurostimulation.

rTMS of medial parieto-occipital cortex interferes with attentional reorienting during attention and reaching tasks

Unexpected changes in the location of a target for an upcoming action require both attentional reorienting and motor planning update. In both macaque and human brain, the medial posterior parietal cortex is involved in both phenomena but its causal role is still unclear. Here we used on-line rTMS over the putative human V6A (pV6A), a reach-related region in the dorsal part of the anterior bank of the parieto-occipital sulcus, during an attention and a reaching task requiring covert shifts of attention and planning of reaching movements toward cued targets in space. We found that rTMS increased RTs to invalidly cued but not to validly cued targets during both the attention and reaching task. Furthermore, we found that rTMS induced a deviation of reaching endpoints toward visual fixation and that this deviation was larger for invalidly cued targets. The results suggest that reorienting signals are used by human pV6A area to rapidly update the current motor plan or the ongoing action when a behaviorally relevant object unexpectedly occurs in an unattended location. The current findings suggest a direct involvement of the action-related dorso-medial visual stream in attentional reorienting and a more specific role of pV6A area in the dynamic, on-line control of reaching actions.

Causal frequency-specific contributions of frontal spatiotemporal patterns induced by non-invasive neurostimulation to human visual performance

Neural oscillatory activity is known to play a crucial role in brain function. In the particular domain of visual perception, specific frequency bands in different brain regions and networks, from sensory areas to large-scale frontoparietal systems, have been associated with distinct aspects of visual behavior. Nonetheless, their contributions to human visual cognition remain to be causally demonstrated. We hereby used non-uniform (and thus non-frequency-specific) and uniform (frequency-specific) high-beta and gamma patterns of noninvasive neurostimulation over the right frontal eye field (FEF) to isolate the behavioral effects of oscillation frequency and provide causal evidence that distinct visual behavioral outcomes could be modulated by frequency-specific activity emerging from a single cortical region. In a visual detection task using near-threshold targets, high-beta frequency enhanced perceptual sensitivity (d') without changing response criterion (beta), whereas gamma frequency shifted response criterion but showed no effects on perceptual sensitivity. The lack of behavioral modulations by non-frequency-specific patterns demonstrates that these behavioral effects were specifically driven by burst frequency. We hypothesize that such frequency-coded behavioral impact of oscillatory activity may reflect a general brain mechanism to multiplex functions within the same neural substrate. Furthermore, pathological conditions involving impaired cerebral oscillations could potentially benefit in the near future from the use of neurostimulation to restore the characteristic oscillatory patterns of healthy systems.

Physiological observations validate finite element models for estimating subject-specific electric field distributions induced by transcranial magnetic stimulation of the human motor cortex

Recent evidence indicates subject-specific gyral folding patterns and white matter anisotropy uniquely shape electric fields generated by TMS. Current methods for predicting the brain regions influenced by TMS involve projecting the TMS coil position or center of gravity onto realistic head models derived from structural and functional imaging data. Similarly, spherical models have been used to estimate electric field distributions generated by TMS pulses delivered from a particular coil location and position. In the present paper we inspect differences between electric field computations estimated using the finite element method (FEM) and projection-based approaches described above. We then more specifically examined an approach for estimating cortical excitation volumes based on individualistic FEM simulations of electric fields. We evaluated this approach by performing neurophysiological recordings during MR-navigated motormapping experiments. We recorded motor evoked potentials (MEPs) in response to single pulse TMS using two different coil orientations (45° and 90° to midline) at 25 different locations (5×5 grid, 1cm spacing) centered on the hotspot of the right first dorsal interosseous (FDI) muscle in left motor cortex. We observed that motor excitability maps varied within and between subjects as a function of TMS coil position and orientation. For each coil position and orientation tested, simulations of the TMS-induced electric field were computed using individualistic FEM models and compared to MEP amplitudes obtained during our motormapping experiments. We found FEM simulations of electric field strength, which take into account subject-specific gyral geometry and tissue conductivity anisotropy, significantly correlated with physiologically observed MEP amplitudes (rmax=0.91, p=1.8×10(-5) rmean=0.81, p=0.01). These observations validate the implementation of individualistic FEM models to account for variations in gyral folding patterns and tissue conductivity anisotropy, which should help improve the targeting accuracy of TMS in the mapping or modulation of human brain circuits.

Temporal accuracy and variability in the left and right posterior parietal cortex

Several brain-imaging and lesion studies have suggested a role for the posterior parietal cortex (PPC) in computing interval-timing tasks. PPC also seems to have a key role in modulating visuospatial mechanisms, which are known to affect temporal performance. By applying transcranial direct current stimulation (tDCS) over the left and right PPC, we aimed to modulate timing ability performance in healthy humans performing a cognitively controlled timing task. In two separate experiments we compared time-processing abilities of two groups of healthy adults submitted to anodal, cathodal or sham tDCS over right or left PPC, by employing a supra-second time reproduction task. Cathodal stimulation over the right PPC affected temporal accuracy by leading participants to overestimate time intervals. Moreover, when applied to the left PPC, it reduced variability in reproducing temporal intervals. No effect was reported for anodal stimulation. These results expand current knowledge on the role of the parietal cortex on temporal processing. We provide evidence that the parietal cortex of both hemispheres is involved in temporal processing by acting on distinct components of timing performance such as accuracy and variability.

Disrupting the brain to validate hypotheses on the neurobiology of language

Comprehension of words is an important part of the language faculty, involving the joint activity of frontal and temporo-parietal brain regions. Transcranial Magnetic Stimulation (TMS) enables the controlled perturbation of brain activity, and thus offers a unique tool to test specific predictions about the causal relationship between brain regions and language understanding. This potential has been exploited to better define the role of regions that are classically accepted as part of the language-semantic network. For instance, TMS has contributed to establish the semantic relevance of the left anterior temporal lobe, or to solve the ambiguity between the semantic vs. phonological function assigned to the left inferior frontal gyrus (LIFG). We consider, more closely, the results from studies where the same technique, similar paradigms (lexical-semantic tasks) and materials (words) have been used to assess the relevance of regions outside the classically-defined language-semantic network—i.e., precentral motor regions—for the semantic analysis of words. This research shows that different aspects of the left precentral gyrus (primary motor and premotor sites) are sensitive to the action-non action distinction of words' meanings. However, the behavioral changes due to TMS over these sites are incongruent with what is expected after perturbation of a task-relevant brain region. Thus, the relationship between motor activity and language-semantic behavior remains far from clear. A better understanding of this issue could be guaranteed by investigating functional interactions between motor sites and semantically-relevant regions.

Can transcranial electrical stimulation improve learning difficulties in atypical brain development? A future possibility for cognitive training

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Transcranial electrical stimulation (TES) can improve cognitive training effects in adults.

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TES can enhance neuroplasticity from the molecular level to the system level.

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We discuss the usage of TES with cognitive training in atypically developing children.

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We discuss the possible cognitive and physical side effects of TES.

Learning difficulties in atypical brain development represent serious obstacles to an individual's future achievements and can have broad societal consequences. Cognitive training can improve learning impairments only to a certain degree. Recent evidence from normal and clinical adult populations suggests that transcranial electrical stimulation (TES), a portable, painless, inexpensive, and relatively safe neuroenhancement tool, applied in conjunction with cognitive training can enhance cognitive intervention outcomes. This includes, for instance, numerical processing, language skills and response inhibition deficits commonly associated with profound learning difficulties and attention-deficit hyperactivity disorder (ADHD). The current review introduces the functional principles, current applications and promising results, and potential pitfalls of TES. Unfortunately, research in child populations is limited at present. We suggest that TES has considerable promise as a tool for increasing neuroplasticity in atypically developing children and may be an effective adjunct to cognitive training in clinical settings if it proves safe. The efficacy and both short- and long-term effects of TES on the developing brain need to be critically assessed before it can be recommended for clinical settings.