Using EEG to explore how rTMS produces its effects on behavior

Enhancing neuroplasticity in major depression: A novel 10 Hz-rTMS protocol is more effective than iTBS

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment in major depressive disorder (MDD). However, intermittent theta-burst stimulation (iTBS) and rTMS protocols using 10 Hz stimulation frequency might differ in their effect on neuroplasticity and on clinical symptoms. This study compares the effect of iTBS and a novel 10 Hz-rTMS with shortened single session duration, on motor excitability and neuroplasticity and on clinical symptoms in MDD.

METHODS

30 patients with MDD received either iTBS or the novel 10 Hz-rTMS daily over three weeks to the left dorsolateral prefrontal cortex. Before and after the interventions, motor excitability, short-latency intracortical inhibition and long-term-potentiation-like plasticity in the motor cortex and clinical symptoms were measured by use of transcranial magnetic stimulation.

RESULTS

After the intervention, the level of neuroplasticity increased and clinical symptoms of depression were reduced in both groups, though both effects were significantly stronger after the novel 10 Hz-rTMS. Importantly, the changes in neuroplasticity and clinical symptoms were correlated: the stronger neuroplasticity increased, the stronger was the improvement of clinical symptoms.

LIMITATIONS

Short intervention period of 3 weeks. Clinical symptoms were measured by self-assessment only and are therefore preliminary.

CONCLUSIONS

The novel 10 Hz-rTMS is more effective in increasing neuroplasticity in MDD and potentially also in reducing clinical symptoms than iTBS. This might be due to a differential mode of action on neuroplasticity and to the stimulation frequency of 10 Hz (within the alpha range) being more suitable to reset the brain's activity and to support neuroplastic changes.

Online and offline effects of parietal 10 Hz repetitive transcranial magnetic stimulation on working memory in healthy controls

Parietal alpha activity shows a specific pattern of phasic changes during working memory. It decreases during the encoding and recall phases but increases during the maintenance phase. This study tested whether online rTMS delivered to the parietal cortex during the maintenance phase of a working memory task would increase alpha activity and hence improve working memory. Then, 46 healthy volunteers were randomly assigned to two groups to receive 3-day parietal 10 Hz online rTMS (either real or sham, 3600 pulses in total) that were time-locked to the maintenance phase of a spatial span task (180 trials in total). Behavioral performance on another spatial span task and EEG signals during a change detection task were recorded on the day before the first rTMS (pretest) and the day after the last rTMS (posttest). We found that rTMS improved performance on both online and offline spatial span tasks. For the offline change detection task, rTMS enhanced alpha activity within the maintenance phase and improved interference control of working memory at both behavioral (K score) and neural (contralateral delay activity) levels. These results suggested that rTMS with alpha frequency time-locked to the maintenance phase is a promising way to boost working memory.

Repetitive Transcranial Magnetic Stimulation (rTMS) in Mild Cognitive Impairment: Effects on Cognitive Functions-A Systematic Review

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technique also used as a non-pharmacological intervention against cognitive impairment. The purpose of the present review was to summarize what is currently known about the effectiveness of rTMS intervention on different cognitive domains in patients with mild cognitive impairment (MCI) and to address potential neuromodulation approaches in combination with electroencephalography (EEG) and neuroimaging, especially functional magnetic resonance imaging (fMRI). In this systematic review, we consulted three main databases (PubMed, Science Direct, and Scopus), and Google Scholar was selected for the gray literature search. The PRISMA flowchart drove the studies' inclusion. The selection process ensured that only high-quality studies were included; after removing duplicate papers, explicit ratings were given based on the quality classification as high (A), moderate (B), or low (C), considering factors such as risks of bias, inaccuracies, inconsistencies, lack of direction, and publication bias. Seven full-text articles fulfilled the stated inclusion, reporting five double-blind, randomized, sham-controlled studies, a case study, and a randomized crossover trial. The results of the reviewed studies suggested that rTMS in MCI patients is safe and effective for enhancing cognitive functions, thus making it a potential therapeutic approach for MCI patients. Changes in functional connectivity within the default mode network (DMN) after targeted rTMS could represent a valuable indicator of treatment response. Finally, high-frequency rTMS over the dorsolateral prefrontal cortex (DLPFC) has been shown to significantly enhance cognitive functions, such as executive performance, together with the increase of functional connectivity within frontoparietal networks. The main limitations were the number of included studies and the exclusion of studies using intermittent theta-burst stimulation, used in studies on Alzheimer's disease. Therefore, neuroimaging techniques in combination with rTMS have been shown to be useful for future network-based, fMRI-guided therapeutic approaches.

Effect of rTMS at SMA on task-based connectivity in PD

BACKGROUND

Transcranial magnetic stimulation (TMS) can aid in alleviating clinical symptoms in Parkinson's disease (PD). To better understand the neural mechanism of the intervention, neuroimaging modalities have been used to assess the effects of rTMS.

OBJECTIVE

To study the changes in cortical connectivity and motor performance with rTMS at supplementary motor area (SMA) in PD using clinical assessment tools and task-based functional MRI.

METHODOLOGY

3000 pulses at 5 Hz TMS were delivered at the left SMA once a week for a total of 8 consecutive weeks in 4 sham sessions (week 1-4) and 4 real sessions (week 5 to week 8) in 16 subjects with PD. The outcomes were assessed with UPDRS, PDQ 39 and task-based fMRI at baseline, after sham sessions at week 4, and after real sessions at week 8. Visuo-spatial functional MRI task along with T1 weighted scans (at 3 Tesla) were used to evaluate the effects of rTMS intervention. Multivariate pattern analysis (MVPA) was used to analyse task-based fMRI using Conn toolbox.

RESULTS

Improvements (p < 0.05) were observed in UPDRS II, III, Mobility and ADL of PDQ39 after real sessions of rTMS. MVPA of task-based connectivity revealed clusters of activation in right hemispheric precentral area, superior frontal gyrus, middle frontal gyrus, thalamus and cerebellum (cluster threshold pFDR=0.001).

CONCLUSIONS

Weekly rTMS sessions at SMA incurred clinical motor benefits as revealed by an improvement in clinical scales and dexterity performance. These benefits could be attributed to changes in connectivity remote brain regions in the motor network.

Noninvasive Brain Stimulation Techniques for Treatment-Resistant Depression: Transcranial Magnetic Stimulation and Transcranial Direct Current Stimulation

Transcranial magnetic stimulation is a safe, effective, and well-tolerated intervention for depression; it is currently approved for treatment-resistant depression. This article summarizes the mechanism of action, evidence of clinical efficacy, and the clinical aspects of this intervention, including patient evaluation, stimulation parameters selection, and safety considerations. Transcranial direct current stimulation is another neuromodulation treatment for depression; although promising, the technique is not currently approved for clinical use in the United States. The final section outlines the open challenges and future directions of the field.

Dissociable causal roles of the frontal and parietal cortices in the effect of object location on object identity detection: a TMS study

According to the spatial congruency advantage, individuals exhibit higher accuracy and shorter reaction times during the visual working memory (VWM) task when VWM test stimuli appear in spatially congruent locations, relative to spatially incongruent locations, during the encoding phase. Functional magnetic resonance imaging studies have revealed changes in right inferior frontal gyrus (rIFG) and right supra-marginal gyrus (rSMG) activity as a function of object location stability. Nevertheless, it remains unclear whether these regions play a role in active object location repositioning or passive early perception of object location stability, and demonstrations of causality are lacking. In this study, we adopted an object identity change-detection task, involving a short train of 10-Hz online repetitive transcranial magnetic stimulations (rTMS) applied at the rIFG or rSMG concurrently with the onset of VWM test stimuli. In two experimental cohorts, we observed an improved accuracy in spatially incongruent high VWM load conditions when the 10 Hz-rTMS was applied at the rIFG compared with that in TMS control conditions, whereas these modulatory effects were not observed for the rSMG. Our results suggest that the rIFG and rSMG play dissociable roles in the spatial congruency effect, whereby the rIFG is engaged in active object location repositioning, while the rSMG is engaged in passive early perception of object location stability.

Simultaneously stimulating both brain hemispheres by rTMS in patients with unilateral brain lesions decreases interhemispheric asymmetry

BACKGROUND

Interhemispheric asymmetry caused by brain lesions is an adverse factor in the recovery of patients with neurological deficits. Repetitive transcranial magnetic stimulation (rTMS) has been shown to modulate cortical oscillation and proposed as an approach to rebalance the symmetry, which has not been documented well.

OBJECTIVE

In this study, we investigated the influence of repetitive transcranial magnetic stimulation (rTMS) on EEG power in patients with unilateral brain lesions by simultaneously stimulating both brain hemispheres and to elucidate asymmetrical changes in rTMS-induced neurophysiological activity.

METHODS

Fourteen patients with unilateral brain lesions were treated with one active and one sham session of 10 Hz rTMS over the vertex (Cz position). Resting-state EEGs were recorded before and immediately after rTMS. The brain symmetry index (BSI), calculated from a fast Fourier transform, was employed to quantify the power asymmetry in both hemispheres and paired channels over the entire range and five frequency bands (delta, theta, alpha, beta and gamma bands).

RESULTS

Comparison between active and sham sessions demonstrated rTMS-induced EEG after-effects. rTMS in the active session significantly reduced the BSI in patients with unilateral brain lesions over the entire frequency range (t = 2.767, P = 0.016). Among the five frequency bands, rTMS only induced a noticeable decrease in the BSI in the delta band (t = 2.254, P = 0.042). Furthermore, analysis of different brain regions showed that significant changes in the BSI of the alpha band were only demonstrated in the posterior parietal lobe. In addition, EEG topographic mapping showed a decreased power of delta oscillations in the ipsilesional hemisphere, whereas distinct cortical oscillations were observed in the alpha band around the parietal-occipital lobe in the contralesional hemisphere.

CONCLUSIONS

When both brain hemispheres were simultaneously activated, rTMS decreased interhemispheric asymmetry primarily via reducing the delta band in the lesioned hemisphere.

Shaping the slow waves of sleep: A systematic and integrative review of sleep slow wave modulation in humans using non-invasive brain stimulation

The experimental study of electroencephalographic slow wave sleep (SWS) stretches over more than half a century and has corroborated its importance for basic physiological processes, such as brain plasticity, metabolism and immune system functioning. Alterations of SWS in aging or pathological conditions suggest that modulating SWS might constitute a window for clinically relevant interventions. This work provides a systematic and integrative review of SWS modulation through non-invasive brain stimulation in humans. A literature search using PubMed, conducted in May 2020, identified 3220 studies, of which 82 fulfilled inclusion criteria. Three approaches have been adopted to modulate the macro- and microstructure of SWS, namely auditory, transcranial electrical and transcranial magnetic stimulation. Our current knowledge about the modulatory mechanisms, the space of stimulation parameters and the physiological and behavioral effects are reported and evaluated. The integration of findings suggests that sleep slow wave modulation bears the potential to promote our understanding of the functions of SWS and to develop new treatments for conditions of disrupted SWS.

Effects of the unilateral dynamic handgrip on resting cortical activity levels: A replication and extension

Previous studies have linked unilateral hand contractions to subsequent changes in hemispheric asymmetric activity, as reflected in the electroencephalographic alpha (8-12 Hz) range in each hemisphere. However, debate continues regarding the state of asymmetry induced by unilateral contractions. We have previously found a bilateral enhancement of alpha amplitude that occurs after contractions, reflecting cortical downregulation instead of changes in asymmetric activity. To corroborate our observations, we examined the effects of 45 s of unilateral dynamic handgrip contractions on subsequent resting alpha activity. Twenty-two right-handed participants were recruited (M = 25 years, 17 female). The study used a within-subjects design consisting of a pre- and post-test (2 min resting; eyes open) for the intervention (dynamic handgrip; at a self-determined pace of approximately twice a second for 45 s for each hand). Following the handgrip task, an increase in alpha amplitude above the baseline was observed over the entire cortex, which was greater after left-hand squeezing. This observation confirms our previous findings and we have extended them by adding more electrodes to gain further insights into the handgrip exercise as an external brain stimulator. Moreover, we grouped electrodes according to scalp regions to facilitate the visualization of the effects on the frequency spectrum. Our findings can be used to develop targeted interventions aimed at modifying behavioral outcomes affected by alpha activity.

Site-Specific Effects of Online rTMS during a Working Memory Task in Healthy Older Adults

The process of manipulating information within working memory is central to many cognitive functions, but also declines rapidly in old age. Improving this process could markedly enhance the health-span in older adults. The current pre-registered, randomized and placebo-controlled study tested the potential of online repetitive transcranial magnetic stimulation (rTMS) applied at 5 Hz over the left lateral parietal cortex to enhance working memory manipulation in healthy elderly adults. rTMS was applied, while participants performed a delayed-response alphabetization task with two individually titrated levels of difficulty. Coil placement and stimulation amplitude were calculated from fMRI activation maps combined with electric field modeling on an individual-subject basis in order to standardize dosing at the targeted cortical location. Contrary to the a priori hypothesis, active rTMS significantly decreased accuracy relative to sham, and only in the hardest difficulty level. When compared to the results from our previous study, in which rTMS was applied over the left prefrontal cortex, we found equivalent effect sizes but opposite directionality suggesting a site-specific effect of rTMS. These results demonstrate engagement of cortical working memory processing using a novel TMS targeting approach, while also providing prescriptions for future studies seeking to enhance memory through rTMS.

Paired Associative Stimulation Rewired: A Novel Paradigm to Modulate Resting-State Intracortical Connectivity

Recent neuroimaging research has demonstrated that resting-state intracortical connectivity (i.e., the shared communication between two brain regions) can serve as a robust predictor of motor performance and learning. Theoretically, direct modulation of resting-state intracortical connectivity within the motor system could then improve motor performance and learning. However, previous neuromodulation techniques such as repetitive Transcranial Magnetic Stimulation may be limited in the capacity to modulate targeted intracortical connectivity. Paired Associative Stimulation (PAS) has shown efficacy in facilitating connectivity primarily between the central and peripheral nervous system based on the neuroplasticity mechanism of Spike Timing Dependent Plasticity. It may therefore be plausible for a reconfigured corticocortical PAS paradigm to modulate resting-state intracortical connectivity using a dual stimulator methodology over specific cortical nodes. However, potential theoretical and technological considerations of such a paradigm first need to be addressed prior to application for the purposes of manipulating motor behavior. We posit a corticocortical PAS paradigm used in conjunction with resting-state electroencephalography to demonstrate efficacy of potentiating motor learning associated resting-state intracortical connectivity within the human brain. Here we provide a precise PAS/EEG experimental design, details on data analysis, recommendations for maintaining scientific rigor, and preliminary proof of principle within a single-subject.

Predictors of response to synchronized transcranial magnetic stimulation for major depressive disorder

BACKGROUND

Synchronized transcranial magnetic stimulation (sTMS) is a new modality to reduce symptoms of major depressive disorder (MDD). sTMS uses rotating neodymium magnets to deliver low-field stimulation matched to the individual alpha frequency (IAF). A previous multisite study showed that sTMS significantly reduced MDD symptoms in the per-protocol sample. To this end, we evaluated clinical features associated with optimal sTMS outcomes.

METHODS

Using the per-protocol sample (n = 120) from the parent sham-controlled trial, we performed univariate and stepwise linear regression to identify predictors of response after 6 weeks of sTMS. A subsample (n = 83) that entered a 4-week open/active continuation phase also was examined. Candidate variables included age, sex, comorbid anxiety, number of failed antidepressants in the current depressive episode, MDD severity (17-item Hamilton Depression Rating Scale; HAMD17), anxiety symptom severity (HAMD17 anxiety/somatization factor), and IAF.

RESULTS

We found that greater baseline depressive (p < 0.001) and anxiety (p < 0.001) symptom severity were associated with better response to active sTMS, whereas fewer failed antidepressant trials predicted superior response to sham (p < 0.001). MDD severity and antidepressant resistance predicted outcomes in open/active phase sTMS; lower IAF predicted poorer response in participants who received 10 weeks of active sTMS (p = 0.001).

CONCLUSIONS

Participants with greater severity of depression and higher anxiety had superior responses to active sTMS, whereas treatment naïve individuals exhibited a greater response to sham. These results lend support to the primary efficacy findings, and support further investigation of sTMS as a therapeutic noninvasive brain stimulation modality.

Rhythmic modulation of thalamic oscillations depends on intrinsic cellular dynamics

OBJECTIVE

Rhythmic brain stimulation has emerged as a powerful tool to modulate cognition and to target pathological oscillations related to neurological and psychiatric disorders. However, we lack a systematic understanding of how periodic stimulation interacts with endogenous neural activity as a function of the brain state and target.

APPROACH

To address this critical issue, we applied periodic stimulation to a unified biophysical thalamic network model that generates multiple distinct oscillations, and examined thoroughly the impact of rhythmic stimulation on different oscillatory states.

MAIN RESULTS

We found that rhythmic perturbation induces four basic response mechanisms: entrainment, acceleration, resonance and suppression. Importantly, the appearance and expression of these mechanisms depend highly on the intrinsic cellular dynamics in each state. Specifically, the low-threshold bursting of thalamocortical cells (TCs) in delta (δ) oscillation renders the network relatively insensitive to entrainment; the high-threshold bursting of TCs in alpha (α) oscillation leads to widespread oscillation suppression while the tonic spiking of TC cells in gamma (γ) oscillation results in prominent entrainment and resonance. In addition, we observed entrainment discontinuity during α oscillation that is mediated by firing pattern switching of high-threshold bursting TC cells. Furthermore, we demonstrate that direct excitatory stimulation of the lateral geniculate nucleus (LGN) entrains thalamic oscillations via an asymmetric Arnold tongue that favors higher frequency entrainment and resonance, while stimulation of the inhibitory circuit, the reticular nucleus, induces much weaker and more symmetric entrainment and resonance. These results support the notion that rhythmic stimulation engages brain oscillations in a state- and target-dependent manner.

SIGNIFICANCE

Overall, our study provides, for the first time, insights into how the biophysics of thalamic oscillations guide the emergence of complex, state-dependent mechanisms of target engagement, which can be leveraged for the future rational design of novel therapeutic stimulation modalities.

Updates on Transcranial Magnetic Stimulation Therapy for Major Depressive Disorder

Transcranial magnetic stimulation has emerged as a treatment option for treatment-resistant depression. While existing data largely support efficacy of transcranial magnetic stimulation for major depressive disorder, ongoing research aims to optimize treatment parameters and identify biomarkers of treatment response. In this article, the authors describe data from controlled trials and ongoing efforts to enhance transcranial magnetic stimulation outcomes for major depressive disorder. Findings from preliminary research aimed at identifying neuroimaging and neurophysiological biomarkers of transcranial magnetic stimulation effects are discussed.

Effects of 20 Hz Repetitive Transcranial Magnetic Stimulation on Disorders of Consciousness: A Resting-State Electroencephalography Study

Repetitive transcranial magnetic stimulation (rTMS) has been proposed as an experimental approach for the treatment of disorders of consciousness (DOC). To date, there has been little research into the use of rTMS in DOC and the therapeutic effects have been variously documented. This study aimed to examine the effects of 20 Hz rTMS on the electroencephalography (EEG) reactivity and clinical response in patients with DOC and to explore the neuromodulatory effects of high-frequency rTMS. In this randomized, sham-controlled, crossover study, real or sham 20 Hz rTMS was applied to the left primary motor cortex (M1) of patients with DOC for 5 consecutive days. Evaluations were blindly performed at the baseline (T0), immediately after the end of the 5 days of treatment (T1) and 1 week after the treatment (T2) using the JFK coma recovery scale-revised (CRS-R) and resting-state EEG. Only one patient, with a history of 2 months of traumatic brain injury, showed long-lasting (T1, T2) behavioral and neurophysiological modifications after the real rTMS stimulation. The 5 remaining patients presented brain reactivity localized at several electrodes, and the EEG modification was not significant. rTMS stimulation may improve awareness and arousal of DOC. Additionally, EEG represents a potential biomarker for the therapeutic efficacy of rTMS. This trial is registered with (NCT03385278).

Comparing the Effects of 10-Hz Repetitive TMS on Tasks of Visual STM and Attention

Numerous studies have demonstrated that visual STM (VSTM) and attention are tightly linked processes that share a number of neuroanatomical substrates. Here, we used repetitive TMS (rTMS) along with simultaneous EEG to examine the causal relationship between intraparietal sulcus functioning and performance on tasks of attention and VSTM. Participants performed two tasks in which they were required to attend to or remember colored items over a brief interval, with 10-Hz rTMS applied on some of the trials. Although no overall behavioral changes were observed across either task, rTMS did affect individual performance on both the attention and VSTM tasks in a manner that was predicted by individual differences in baseline performance. Furthermore, rTMS also affected ongoing oscillations in the alpha and beta bands, and these changes were related to the observed change in behavioral performance. The results reveal a causal relationship between intraparietal sulcus activity and tasks measuring both visual attention and VSTM.

Experiments and models of cortical oscillations as a target for noninvasive brain stimulation

Noninvasive brain stimulation is attracting substantial attention due to its potential for safe and effective modulation of brain network dynamics. Promising applications include cognitive enhancement and treatment of disorders of the central nervous system. Recently, targeting of cortical oscillations by brain stimulation with periodic electromagnetic waveforms has emerged as a particularly appealing approach for understanding the causal role of cortical oscillations in human cognition and behavior. Two main approaches exist: repetitive transcranial magnetic stimulation (rTMS) and transcranial alternating current stimulation (tACS); rTMS is more widely used as a research and clinical tool but only recently has it been suggested to selectively engage frequency-matched cortical oscillations. In contrast, tACS is an offspring of transcranial direct current stimulation and has been introduced with the specific aim of engaging cortical oscillations. One of the main lessons that the field of noninvasive brain stimulation has learned over the last few years is that without a mechanistic understanding of how stimulation engages neuronal circuits, little progress can be made toward the rational design of individualized, adaptive stimulation treatments. Computer simulations of cellular and network models from the field of computational neuroscience are a key tool to gain such a mechanistic understanding. However, the insights gained from such modeling strategies can only be fully leveraged when used in tight conjunction with experimental approaches in both human and animal model studies. Here, I provide an in-depth review of the pioneering experimental and computational studies that together provide the basis for understanding how periodic noninvasive brain stimulation targets cortical oscillations to enable the rational design of brain stimulation treatments for disorders associated with specific deficits in cortical oscillations.

Altered structure of dynamic electroencephalogram oscillatory pattern in major depression

Research on electroencephalogram (EEG) characteristics associated with major depressive disorder (MDD) has accumulated diverse neurophysiologic findings related to the content, topography, neurochemistry, and functions of EEG oscillations. Significant progress has been made since the first landmark EEG study on affective disorders by Davidson 35 years ago. A systematic account of these data is important and necessary for building a consistent neuropsychophysiologic model of MDD and other affective disorders. Given the extensive data on frequency-dependent functional significance of EEG oscillations, a frequency domain approach may reveal the types of brain functions involved and disturbed in MDD. In this review, we systematize and integrate diverse and often unconnected observations on the content, topography, neurochemistry, and functions of EEG oscillations involved in MDD within the general concept of an EEG oscillatory pattern.

Ketamine and transcranial magnetic stimulation treatment for bipolar II disorder: a case report

Introduction

To the best of our knowledge, this is the first case report of successful treatment for bipolar II disorder using a combined ketamine and transcranial magnetic stimulation treatment.

Case presentation

A 43-year-old Caucasian unemployed man presented to us with treatment-resistant bipolar II disorder, currently in a mixed state. A psychometric assessment and brain single-photon emission computer tomography scan were conducted at baseline. His psychometric assessment revealed severe depressive and manic symptoms that were consistent with bipolar II disorder. Findings from a brain single-photon emission computer tomography scan converged with those from his psychometric assessment. The combined ketamine and transcranial magnetic stimulation treatment was administered a total of 24 times over five months, with his ketamine dosage increased from 50mg at the first treatment to 600mg by the last. Starting after the second treatment, he reported substantial improvements in his symptoms. A follow-up psychometric assessment and brain single-photon emission computer tomography scan five months later revealed substantial blood flow increases in the previously deficient areas.

Conclusions

We provide preliminary evidence for a treatment method that magnifies the therapeutic benefits of infused ketamine along with transcranial magnetic stimulation. We postulate that this may be based on an interaction at the level of the relevant cortico-thalamo-cortical circuit(s).

Rhythms and blues: modulation of oscillatory synchrony and the mechanism of action of antidepressant treatments

Treatments for major depressive disorder (MDD) act at different hierarchical levels of biological complexity, ranging from the individual synapse to the brain as a whole. Theories of antidepressant medication action traditionally have focused on the level of cell-to-cell interaction and synaptic neurotransmission. However, recent evidence suggests that modulation of synchronized electrical activity in neuronal networks is a common effect of antidepressant treatments, including not only medications, but also neuromodulatory treatments such as repetitive transcranial magnetic stimulation. Synchronization of oscillatory network activity in particular frequency bands has been proposed to underlie neurodevelopmental and learning processes, and also may be important in the mechanism of action of antidepressant treatments. Here, we review current research on the relationship between neuroplasticity and oscillatory synchrony, which suggests that oscillatory synchrony may help mediate neuroplastic changes related to neurodevelopment, learning, and memory, as well as medication and neuromodulatory treatment for MDD. We hypothesize that medication and neuromodulation treatments may have related effects on the rate and pattern of neuronal firing, and that these effects underlie antidepressant efficacy. Elucidating the mechanisms through which oscillatory synchrony may be related to neuroplasticity could lead to enhanced treatment strategies for MDD.

EEG oscillations: From correlation to causality

Already in his first report on the discovery of the human EEG in 1929, Berger showed great interest in further elucidating the functional roles of the alpha and beta waves for normal mental activities. Meanwhile, most cognitive processes have been linked to at least one of the traditional frequency bands in the delta, theta, alpha, beta, and gamma range. Although the existing wealth of high-quality correlative EEG data led many researchers to the conviction that brain oscillations subserve various sensory and cognitive processes, a causal role can only be demonstrated by directly modulating such oscillatory signals. In this review, we highlight several methods to selectively modulate neuronal oscillations, including EEG-neurofeedback, rhythmic sensory stimulation, repetitive transcranial magnetic stimulation (rTMS), and transcranial alternating current stimulation (tACS). In particular, we discuss tACS as the most recent technique to directly modulate oscillatory brain activity. Such studies demonstrating the effectiveness of tACS comprise reports on purely behavioral or purely electrophysiological effects, on combination of behavioral effects with offline EEG measurements or on simultaneous (online) tACS-EEG recordings. Whereas most tACS studies are designed to modulate ongoing rhythmic brain activity at a specific frequency, recent evidence suggests that tACS may also modulate cross-frequency interactions. Taken together, the modulation of neuronal oscillations allows to demonstrate causal links between brain oscillations and cognitive processes and to obtain important insights into human brain function.

Transcranial brain stimulation to promote functional recovery after stroke

Purpose of review

Noninvasive brain stimulation (NIBS) is increasingly used to enhance the recovery of function after stroke. The purpose of this review is to highlight and discuss some unresolved questions that need to be addressed to better understand and exploit the potential of NIBS as a therapeutic tool.

Recent findings

Recent meta-analyses showed that the treatment effects of NIBS in patients with stroke are rather inconsistent across studies and the evidence for therapeutic efficacy is still uncertain. This raises the question of how NIBS can be developed further to improve its therapeutic efficacy.

Summary

This review addressed six questions: How does NIBS facilitate the recovery of function after stroke? Which brain regions should be targeted by NIBS? Is there a particularly effective NIBS modality that should be used? Does the location of the stroke influence the therapeutic response? How often should NIBS be repeated? Is the functional state of the brain during or before NIBS relevant to therapeutic efficacy of NIBS? We argue that these questions need to be tackled to obtain sufficient mechanistic understanding of how NIBS facilitates the recovery of function. This knowledge will be critical to fully unfold the therapeutic effects of NIBS and will pave the way towards adaptive NIBS protocols, in which NIBS is tailored to the individual patient.

Perfusion MRI indexes variability in the functional brain effects of theta-burst transcranial magnetic stimulation

Transcranial Magnetic Stimulation (TMS) is an important tool for testing causal relationships in cognitive neuroscience research. However, the efficacy of TMS can be variable across individuals and difficult to measure. This variability is especially a challenge when TMS is applied to regions without well-characterized behavioral effects, such as in studies using TMS on multi-modal areas in intrinsic networks. Here, we examined whether perfusion fMRI recordings of Cerebral Blood Flow (CBF), a quantitative measure sensitive to slow functional changes, reliably index variability in the effects of stimulation. Twenty-seven participants each completed four combined TMS-fMRI sessions during which both resting state Blood Oxygen Level Dependent (BOLD) and perfusion Arterial Spin Labeling (ASL) scans were recorded. In each session after the first baseline day, continuous theta-burst TMS (TBS) was applied to one of three locations: left dorsolateral prefrontal cortex (L dlPFC), left anterior insula/frontal operculum (L aI/fO), or left primary somatosensory cortex (L S1). The two frontal targets are components of intrinsic networks and L S1 was used as an experimental control. CBF changes were measured both before and after TMS on each day from a series of interleaved resting state and perfusion scans. Although TBS led to weak selective increases under the coil in CBF measurements across the group, individual subjects showed wide variability in their responses. TBS-induced changes in rCBF were related to TBS-induced changes in functional connectivity of the relevant intrinsic networks measured during separate resting-state BOLD scans. This relationship was selective: CBF and functional connectivity of these networks were not related before TBS or after TBS to the experimental control region (S1). Furthermore, subject groups with different directions of CBF change after TBS showed distinct modulations in the functional interactions of targeted networks. These results suggest that CBF is a marker of individual differences in the effects of TBS.

Frontal midline theta oscillations during working memory maintenance and episodic encoding and retrieval

Neural oscillations in the theta band (4-8 Hz) are prominent in the human electroencephalogram (EEG), and many recent electrophysiological studies in animals and humans have implicated scalp-recorded frontal midline theta (FMT) in working memory and episodic memory encoding and retrieval processes. However, the functional significance of theta oscillations in human memory processes remains largely unknown. Here, we review studies in human and animals examining how scalp-recorded FMT relates to memory behaviors and also their possible neural generators. We also discuss models of the functional relevance of theta oscillations to memory processes and suggest promising directions for future research.

Fast entrainment of human electroencephalogram to a theta-band photic flicker during successful memory encoding

Theta band power (4–8 Hz) in the scalp electroencephalogram (EEG) is thought to be stronger during memory encoding for subsequently remembered items than for forgotten items. According to simultaneous EEG-functional magnetic resonance imaging (fMRI) measurements, the memory-dependent EEG theta is associated with multiple regions of the brain. This suggests that the multiple regions cooperate with EEG theta synchronization during successful memory encoding. However, a question still remains: What kind of neural dynamic organizes such a memory-dependent global network? In this study, the modulation of the EEG theta entrainment property during successful encoding was hypothesized to lead to EEG theta synchronization among a distributed network. Then, a transient response of EEG theta to a theta-band photic flicker with a short duration was evaluated during memory encoding. In the results, flicker-induced EEG power increased and decreased with a time constant of several hundred milliseconds following the onset and the offset of the flicker, respectively. Importantly, the offset response of EEG power was found to be significantly decreased during successful encoding. Moreover, the offset response of the phase locking index was also found to associate with memory performance. According to computational simulations, the results are interpreted as a smaller time constant (i.e., faster response) of a driven harmonic oscillator rather than a change in the spontaneous oscillatory input. This suggests that the fast response of EEG theta forms a global EEG theta network among memory-related regions during successful encoding, and it contributes to a flexible formation of the network along the time course.

Personalized medicine in psychiatry: problems and promises

The central theme of personalized medicine is the premise that an individual's unique physiologic characteristics play a significant role in both disease vulnerability and in response to specific therapies. The major goals of personalized medicine are therefore to predict an individual's susceptibility to developing an illness, achieve accurate diagnosis, and optimize the most efficient and favorable response to treatment. The goal of achieving personalized medicine in psychiatry is a laudable one, because its attainment should be associated with a marked reduction in morbidity and mortality. In this review, we summarize an illustrative selection of studies that are laying the foundation towards personalizing medicine in major depressive disorder, bipolar disorder, and schizophrenia. In addition, we present emerging applications that are likely to advance personalized medicine in psychiatry, with an emphasis on novel biomarkers and neuroimaging.

The relationship between brain oscillatory activity and therapeutic effectiveness of transcranial magnetic stimulation in the treatment of major depressive disorder

Major depressive disorder (MDD) is marked by disturbances in brain functional connectivity. This connectivity is modulated by rhythmic oscillations of brain electrical activity, which enable coordinated functions across brain regions. Oscillatory activity plays a central role in regulating thinking and memory, mood, cerebral blood flow, and neurotransmitter levels, and restoration of normal oscillatory patterns is associated with effective treatment of MDD. Repetitive transcranial magnetic stimulation (rTMS) is a robust treatment for MDD, but the mechanism of action (MOA) of its benefits for mood disorders remains incompletely understood. Benefits of rTMS have been tied to enhanced neuroplasticity in specific brain pathways. We summarize here the evidence that rTMS entrains and resets thalamocortical oscillators, normalizes regulation and facilitates reemergence of intrinsic cerebral rhythms, and through this mechanism restores normal brain function. This entrainment and resetting may be a critical step in engendering neuroplastic changes and the antidepressant effects of rTMS. It may be possible to modify the method of rTMS administration to enhance this MOA and achieve better antidepressant effectiveness. We propose that rTMS can be administered: (1) synchronized to a patient's individual alpha frequency (IAF), or synchronized rTMS (sTMS); (2) as a low magnetic field strength sinusoidal waveform; and, (3) broadly to multiple brain areas simultaneously. We present here the theory and evidence indicating that these modifications could enhance the therapeutic effectiveness of rTMS for the treatment of MDD.

Making waves in the stream of consciousness: entraining oscillations in EEG alpha and fluctuations in visual awareness with rhythmic visual stimulation

Rhythmic events are common in our sensory world. Temporal regularities could be used to predict the timing of upcoming events, thus facilitating their processing. Indeed, cognitive theories have long posited the existence of internal oscillators whose timing can be entrained to ongoing periodic stimuli in the environment as a mechanism of temporal attention. Recently, recordings from primate brains have shown electrophysiological evidence for these hypothesized internal oscillations. We hypothesized that rhythmic visual stimuli can entrain ongoing neural oscillations in humans, locking the timing of the excitability cycles they represent and thus enhancing processing of subsequently predictable stimuli. Here we report evidence for entrainment of neural oscillations by predictable periodic stimuli in the alpha frequency band and show for the first time that the phase of existing brain oscillations cannot only be modified in response to rhythmic visual stimulation but that the resulting phase-locked fluctuations in excitability lead to concomitant fluctuations in visual awareness in humans. This entrainment effect was dependent on both the amount of spontaneous alpha power before the experiment and the level of 12-Hz oscillation before each trial and could not be explained by evoked activity. Rhythmic fluctuations in awareness elicited by entrainment of ongoing neural excitability cycles support a proposed role for alpha oscillations as a pulsed inhibition of cortical activity. Furthermore, these data provide evidence for the quantized nature of our conscious experience and reveal a powerful mechanism by which temporal attention as well as perceptual snapshots can be manipulated and controlled.

Dissociating the role of prefrontal and premotor cortices in controlling inhibitory mechanisms during motor preparation

Top-down control processes are critical to select goal-directed actions in flexible environments. In humans, these processes include two inhibitory mechanisms that operate during response selection: one is involved in solving a competition between different response options, the other ensures that a selected response is initiated in a timely manner. Here, we evaluated the role of dorsal premotor cortex (PMd) and lateral prefrontal cortex (LPF) of healthy subjects in these two forms of inhibition by using an innovative transcranial magnetic stimulation (TMS) protocol combining repetitive TMS (rTMS) over PMd or LPF and a single pulse TMS (sTMS) over primary motor cortex (M1). sTMS over M1 allowed us to assess inhibitory changes in corticospinal excitability, while rTMS was used to produce transient disruption of PMd or LPF. We found that rTMS over LPF reduces inhibition associated with competition resolution, whereas rTMS over PMd decreases inhibition associated with response impulse control. These results emphasize the dissociable contributions of these two frontal regions to inhibitory control during motor preparation. The association of LPF with competition resolution is consistent with the role of this area in relatively abstract aspects of control related to goal maintenance, ensuring that the appropriate response is selected in a variable context. In contrast, the association of PMd with impulse control is consistent with the role of this area in more specific processes related to motor preparation and initiation.

Entrainment of perceptually relevant brain oscillations by non-invasive rhythmic stimulation of the human brain

The notion of driving brain oscillations by directly stimulating neuronal elements with rhythmic stimulation protocols has become increasingly popular in research on brain rhythms. Induction of brain oscillations in a controlled and functionally meaningful way would likely prove highly beneficial for the study of brain oscillations, and their therapeutic control. We here review conventional and new non-invasive brain stimulation protocols as to their suitability for controlled intervention into human brain oscillations. We focus on one such type of intervention, the direct entrainment of brain oscillations by a periodic external drive. We review highlights of the literature on entraining brain rhythms linked to perception and attention, and point out controversies. Behaviourally, such entrainment seems to alter specific aspects of perception depending on the frequency of stimulation, informing models on the functional role of oscillatory activity. This indicates that human brain oscillations and function may be promoted in a controlled way by focal entrainment, with great potential for probing into brain oscillations and their causal role.

Rhythmic TMS causes local entrainment of natural oscillatory signatures

Background

Neuronal elements underlying perception, cognition, and action exhibit distinct oscillatory phenomena, measured in humans by electro- or magnetoencephalography (EEG/MEG). So far, the correlative or causal nature of the link between brain oscillations and functions has remained elusive. A compelling demonstration of causality would primarily generate oscillatory signatures that are known to correlate with particular cognitive functions and then assess the behavioral consequences. Here, we provide the first direct evidence for causal entrainment of brain oscillations by transcranial magnetic stimulation (TMS) using concurrent EEG.

Results

We used rhythmic TMS bursts to directly interact with an MEG-identified parietal α-oscillator, activated by attention and linked to perception. With TMS bursts tuned to its preferred α-frequency (α-TMS), we confirmed the three main predictions of entrainment of a natural oscillator: (1) that α-oscillations are induced during α-TMS (reproducing an oscillatory signature of the stimulated parietal cortex), (2) that there is progressive enhancement of this α-activity (synchronizing the targeted, α-generator to the α-TMS train), and (3) that this depends on the pre-TMS phase of the background α-rhythm (entrainment of natural, ongoing α-oscillations). Control conditions testing different TMS burst profiles and TMS-EEG in a phantom head confirmed specificity of α-boosting to the case of synchronization between TMS train and neural oscillator.

Conclusions

The periodic electromagnetic force that is generated during rhythmic TMS can cause local entrainment of natural brain oscillations, emulating oscillatory signatures activated by cognitive tasks. This reveals a new mechanism of online TMS action on brain activity and can account for frequency-specific behavioral TMS effects at the level of biologically relevant rhythms.

Evoked potentials in large-scale cortical networks elicited by TMS of the visual cortex

Single pulses of transcranial magnetic stimulation (TMS) result in distal and long-lasting oscillations, a finding directly challenging the virtual lesion hypothesis. Previous research supporting this finding has primarily come from stimulation of the motor cortex. We have used single-pulse TMS with simultaneous EEG to target seven brain regions, six of which belong to the visual system [left and right primary visual area V1, motion-sensitive human middle temporal cortex, and a ventral temporal region], as determined with functional MRI-guided neuronavigation, and a vertex "control" site to measure the network effects of the TMS pulse. We found the TMS-evoked potential (TMS-EP) over visual cortex consists mostly of site-dependent theta- and alphaband oscillations. These site-dependent oscillations extended beyond the stimulation site to functionally connected cortical regions and correspond to time windows where the EEG responses maximally diverge (40, 200, and 385 ms). Correlations revealed two site-independent oscillations ∼350 ms after the TMS pulse: a theta-band oscillation carried by the frontal cortex, and an alpha-band oscillation over parietal and frontal cortical regions. A manipulation of stimulation intensity at one stimulation site (right hemisphere V1-V3) revealed sensitivity to the stimulation intensity at different regions of cortex, evidence of intensity tuning in regions distal to the site of stimulation. Together these results suggest that a TMS pulse applied to the visual cortex has a complex effect on brain function, engaging multiple brain networks functionally connected to the visual system with both invariant and site-specific spatiotemporal dynamics. With this characterization of TMS, we propose an alternative to the virtual lesion hypothesis. Rather than a technique that simulates lesions, we propose TMS generates natural brain signals and engages functional networks.

Pulsed out of awareness: EEG alpha oscillations represent a pulsed-inhibition of ongoing cortical processing

Alpha oscillations are ubiquitous in the brain, but their role in cortical processing remains a matter of debate. Recently, evidence has begun to accumulate in support of a role for alpha oscillations in attention selection and control. Here we first review evidence that 8-12 Hz oscillations in the brain have a general inhibitory role in cognitive processing, with an emphasis on their role in visual processing. Then, we summarize the evidence in support of our recent proposal that alpha represents a pulsed-inhibition of ongoing neural activity. The phase of the ongoing electroencephalography can influence evoked activity and subsequent processing, and we propose that alpha exerts its inhibitory role through alternating microstates of inhibition and excitation. Finally, we discuss evidence that this pulsed-inhibition can be entrained to rhythmic stimuli in the environment, such that preferential processing occurs for stimuli at predictable moments. The entrainment of preferential phase may provide a mechanism for temporal attention in the brain. This pulsed inhibitory account of alpha has important implications for many common cognitive phenomena, such as the attentional blink, and seems to indicate that our visual experience may at least some times be coming through in waves.