Suppression of motor cortical excitability by magnetic stimulation of the cerebellum

Dual-site TMS as a tool to probe effective interactions within the motor network: a review

Dual-site transcranial magnetic stimulation (ds-TMS) is well suited to investigate the causal effect of distant brain regions on the primary motor cortex, both at rest and during motor performance and learning. However, given the broad set of stimulation parameters, clarity about which parameters are most effective for identifying particular interactions is lacking. Here, evidence describing inter- and intra-hemispheric interactions during rest and in the context of motor tasks is reviewed. Our aims are threefold: (1) provide a detailed overview of ds-TMS literature regarding inter- and intra-hemispheric connectivity; (2) describe the applicability and contributions of these interactions to motor control, and; (3) discuss the practical implications and future directions. Of the 3659 studies screened, 109 were included and discussed. Overall, there is remarkable variability in the experimental context for assessing ds-TMS interactions, as well as in the use and reporting of stimulation parameters, hindering a quantitative comparison of results across studies. Further studies examining ds-TMS interactions in a systematic manner, and in which all critical parameters are carefully reported, are needed.

Non-invasive cerebellar stimulation--a consensus paper

The field of neurostimulation of the cerebellum either with transcranial magnetic stimulation (TMS; single pulse or repetitive (rTMS)) or transcranial direct current stimulation (tDCS; anodal or cathodal) is gaining popularity in the scientific community, in particular because these stimulation techniques are non-invasive and provide novel information on cerebellar functions. There is a consensus amongst the panel of experts that both TMS and tDCS can effectively influence cerebellar functions, not only in the motor domain, with effects on visually guided tracking tasks, motor surround inhibition, motor adaptation and learning, but also for the cognitive and affective operations handled by the cerebro-cerebellar circuits. Verbal working memory, semantic associations and predictive language processing are amongst these operations. Both TMS and tDCS modulate the connectivity between the cerebellum and the primary motor cortex, tuning cerebellar excitability. Cerebellar TMS is an effective and valuable method to evaluate the cerebello-thalamo-cortical loop functions and for the study of the pathophysiology of ataxia. In most circumstances, DCS induces a polarity-dependent site-specific modulation of cerebellar activity. Paired associative stimulation of the cerebello-dentato-thalamo-M1 pathway can induce bidirectional long-term spike-timing-dependent plasticity-like changes of corticospinal excitability. However, the panel of experts considers that several important issues still remain unresolved and require further research. In particular, the role of TMS in promoting cerebellar plasticity is not established. Moreover, the exact positioning of electrode stimulation and the duration of the after effects of tDCS remain unclear. Future studies are required to better define how DCS over particular regions of the cerebellum affects individual cerebellar symptoms, given the topographical organization of cerebellar symptoms. The long-term neural consequences of non-invasive cerebellar modulation are also unclear. Although there is an agreement that the clinical applications in cerebellar disorders are likely numerous, it is emphasized that rigorous large-scale clinical trials are missing. Further studies should be encouraged to better clarify the role of using non-invasive neurostimulation techniques over the cerebellum in motor, cognitive and psychiatric rehabilitation strategies.

The cerebellum in dystonia - help or hindrance?

Dystonia has historically been considered a disorder of the basal ganglia. This review aims to critically examine the evidence for a role of the cerebellum in the pathophysiology of dystonia. We compare and attempt to link the information available from both clinical and experimental studies; work detailing cerebellar connectivity in primates; data that suggests a role for the cerebellum in the genesis of dystonia in murine models; clinical observation in humans with structural lesions and heredodegenerative disorders of the cerebellum; and imaging studies of patients with dystonia. The typical electrophysiological findings in dystonia are the converse to those found in cerebellar lesions. However, certain subtypes of dystonia mirror cerebellar patterns of increased cortical inhibition. Furthermore, altered cerebellar function can be demonstrated in adult onset focal dystonia with impaired cerebellar inhibition of motor cortex and abnormal eyeblink classical conditioning. We propose that abnormal, likely compensatory activity of the cerebellum is an important factor within pathophysiological models of dystonia. Work in this exciting area has only just begun but it is likely that the cerebellum will have a key place within future models of dystonia.

Cerebellar brain inhibition is decreased in active and surround muscles at the onset of voluntary movement

Highly selective activation of the desired muscles for each movement and inhibition of adjacent muscles is attributed to surround inhibition (SI) which differentially modulates corticospinal excitability in active and surrounding muscles. Cerebellar brain inhibition (CBI) is another inhibitory neuronal network which is known to be active at rest and during tonic muscle contraction. The way in which CBI may be modulated at movement onset and its relationship with SI has not previously been investigated. We assessed motor evoked potential (MEP) size and CBI in first dorsal interosseus (FDI) and abductor digiti minimi (ADM) muscles at rest and during a simple motor task where FDI was an active muscle and ADM was not involved in the movement (surround muscle). At onset of movement, MEP size in ADM was significantly suppressed, confirming the existence of SI. In contrast, CBI in both muscles was found to be significantly decreased at the onset of the movement. This was confirmed even after adjustments for changes in MEP size occurring due to onset of muscle activity in FDI and the effects of SI in ADM. Our findings fail to functionally link SI with CBI, but they do indicate a non-topographically specific modulation of CBI in association with initiation of voluntary movement.

[Basic mechanism of magnetic human cerebellar stimulation and its clinical application]

I here summarize the history of cerebellar stimulation experiments in humans and give some caution to use this stimulation method. In clinical evaluation, we consider the cerebellum as a kind of computer to get information from the peripheral structures and also higher motor cortical centers including the primary motor cortex (M1) and send a cerebellar command to M1 after computation of much information. We study functions of the cerebello-afferent and cerebello-efferent connections using cerebellar stimulation and differentiate these pathways dysfunction. We first activated the cerebellum using electrical stimulation. The most effective position, effective current direction and the interval of conditioning and test stimuli suggested that the observed effect might be produced by some cerebellar structures activation. Studies of cerebellar ataxia patients and other disorders supported the idea that the suppression is produced by the inhibition of dentato-thalamo-cortical pathway by Purkinje cell activation. In patients with a lesion at cerebellar hemisphere, dentate nucleus, superior cerebellar peduncle, motor thalamus, the suppression effect was not evoked. In contrast, the suppression was normally elicited in patients with a lesion at pontine nucleus, middle cerebellar peduncle even though they had clinically definite ataxia. Normal suppression was evoked in patients with non-cerebellar ataxia (sensory ataxia due to paraneoplastic syndrome, tabes dorsalis, ataxic sensory neuropathy). Based on these results, we concluded that the cerebellar electrical stimulation method was useful to differentiate cerebellar ataxia due to cerebellar efferent pathways lesions from other cerebellar ataxia and non-cerebellar ataxia. We demonstrated that magnetic stimulation over the cerebellum using a double-cone coil can produce the same effect as those elicited by electrical cerebellar stimulation. These all results supported the proposal that the magnetic stimulation over the cerebellum can enable us to differentiate the cerebellar efferent ataxia from other cerebellar ataxia and non-cerebellar ataxia. A recent paper has cautioned us to conclude the observed phenomenon to be produced by cerebellar activation after exclusion of several other factors as stated in the original paper. The most serious factor to exclude is the antidromic activation of the corticospinal tracts by the cerebellar stimulation conditioning stimulus. To exclude this possibility, it is important how to measure the threshold of the corticospinal tracts. We recommend that we should use rectified EMG recordings when determining it. In summary, I conclude that the cerebellar magnetic stimulation is a good tool for physiological differentiation of cerebellar ataxia mechanisms in ataxic patients. At a current stage, I recommend a conservative method mentioned in the editorial paper for magnetic cerebellar stimulation.

Modulatory effects of 1 Hz rTMS over the cerebellum on motor cortex excitability

Clinical observations and data from animal experiments point to a physiological facilitatory influence of the deep cerebellar structures on the motor system through the cerebello-thalamo-cortical pathways. The aim of the present study was to explore the long-term effects of low-frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) over the cerebellum on short intracortical inhibition (SICI) and facilitation (ICF) of the motor cortex in normal subjects. Eight healthy subjects (mean age 26.9 +/- 3.1) underwent 1 Hz frequency rTMS delivered on the right cerebellar hemisphere. Before and after cerebellar rTMS, SICI and ICF were assessed in the motor cortex contralateral to the stimulated cerebellar hemisphere by means of a paired pulse paradigm with a conditioning subthreshold stimulus set to 80% of the motor threshold (MT) followed by a testing stimulus at 120% of MT intensity. Five different interstimulus intervals (ISIs) were used to assess SICI (2 and 4 ms) and ICF (7, 10 and 15 ms). Amplitude of the responses was expressed as the percentage of motor evoked potential (MEP) to test stimulus alone. Results showed a significant decrease of ICF at 10 ms ISI that persisted up to 20 min after cerebellar rTMS. This was the only significant modulatory effect of cerebellar stimulation on intracortical motor excitability A suppressive effect of the low-frequency TMS on Purkinje cells could be supposed, even if, the lack of effects on other facilitatory ISIs, stands for more complex modulatory effects of rTMS over cerebellum. The study is a further demonstration that rTMS over the cerebellum induces a long-lasting modulatory effect on the excitability of the interconnected motor area.

Modulation of steady-state auditory evoked potentials by cerebellar rTMS

Steady-state auditory evoked responses (SSAER) obtained via electroencephalography (EEG) co-vary in amplitude with blood flow changes in the auditory area of the cerebellum. The aim of the present EEG study was to probe the cerebellar role in the control of such SSAER. For this purpose, we investigated changes in SSAERs due to transient disruption of the cerebellar hemisphere by repetitive transcranial magnetic stimulation (rTMS). SSAERs to click-trains of three different frequencies in the gamma-band (32, 40 and 47 Hz) were recorded from 45 scalp electrodes in six healthy volunteers immediately after 1-Hz rTMS and compared to baseline SSAERs assessed prior to magnetic stimulation. Cerebellar rTMS contralateral to the stimulated ear significantly reduced the amplitude of steady-state responses to 40-Hz click-trains and showed a tendency to reduce the amplitude to 32-Hz click-trains. No effects were observed for 47-Hz click-trains, nor for magnetic stimulation of the cerebellum ipsilateral to auditory stimulation or after sham stimulation. Our results suggest that interference with cerebellar output by rTMS modifies functional activity associated with cortical auditory processing. The finding of maximum effects on 40-Hz SSAERs provides support to the notion that the cerebellum is part of a distributed network involved in the regulation of cortical oscillatory activity and points at some frequency-specificity for the control of auditory-driven neuronal oscillations.

Facilitatory effect on the motor cortex by electrical stimulation over the cerebellum in humans

Electrical stimulation over the cerebellum is known to transiently suppress the contralateral motor cortex in humans. However, projections from the cerebellar nuclei to the primary motor cortex are disynaptic excitatory pathways through the ventral thalamus. In the present investigation we studied facilitatory effects on the motor cortical excitability elicited by electrical stimulation over the cerebellum by recording surface electromyographic (EMG) responses from the first dorsal interosseous (FDI) muscle in nine normal volunteers. For primary motor cortical activation magnetic stimuli were given over the contralateral hand motor area with a figure-of-eight shaped coil with a current to preferentially elicit I3-waves (test stimulus). For cerebellar stimulation high-voltage electric stimuli were given with an anode on the ipsilateral mastoid process and a cathode over the contralateral process as previously described (conditioning stimulus). The effect of conditioning-test interstimulus intervals was investigated. Anodal cerebellar stimuli increased the size of EMG responses to magnetic cortical stimulation at an interstimulus interval of 3 ms. Reversing the current of conditioning stimulus abolished the facilitation. The same (anodal) conditioning stimuli did not affect electrically evoked cortical responses. Based on the effective polarity of the conditioning stimulus and the time course of facilitation we consider that this effect is due to motor cortical facilitation elicited by activation of the excitatory dentatothalamocortical pathway at the deep cerebellar nuclei or superior cerebellar peduncle. We conclude that the motor cortical facilitation is evoked by cerebellar stimulation in humans.

Transcranial magnetic stimulation: neurophysiological applications and safety

TMS is a non-invasive tool for measuring neural conduction and processing time, activation thresholds, facilitation and inhibition in brain cortex, and neural connections in humans. It is used to study motor, visual, somatosensory, and cognitive functions. TMS does not appear to cause long-term adverse neurological, cardiovascular, hormonal, motor, sensory, or cognitive effects in healthy subjects. Single-pulse (<1Hz) TMS is safe in normal subjects. High frequency, high-intensity repetitive TMS (rTMS) can elicit seizures even in normal subjects. Safety guidelines for using rTMS have been published.

Early visual cortical processing suggested by transcranial magnetic stimulation

Single-pulse transcranial magnetic stimulation (TMS) was applied to the occipital pole of healthy subjects while they performed a forced-choice visual letter-identification task. Pulses were applied on the midline but with a left-right asymmetric polarity; pulse application occurred at a variable delay after letter presentation onset; letters were presented in left or right hemifield. Averaging data over subjects and hemifields showed that performance attained local minima at 20 ms and 100 ms; averaging data over subjects and delays showed that performance was biased towards the same hemifield during both delay intervals; averaging data over subjects showed that the hemifield bias progressively decreased from 20 ms to 50 ms. The data are consistent with the possibility that also the earlier delay interval reflects visual cortical processing.

Increased variability of paced finger tapping accuracy following repetitive magnetic stimulation of the cerebellum in humans

Imaging and lesion studies suggest that the cerebellum is involved in the self-generation of timed motor responses. Using repetitive transcranial magnetic stimulation (rTMS), we studied the effects of transient disruption of the lateral or medial cerebellum on a paced-finger-tapping task (PFT). Results show greater variability on the PFT task following a 5 min train of 1 Hz rTMS to the medial cerebellum. Magnetic stimulation of the lateral cerebellum or motor cortex, and sham stimulation, had no effect on performance. Expanding the results of neuroimaging studies, these data show the causal link between activity in the medial cerebellum and the production of timed movements. This is the first demonstration of the feasibility of transiently disrupting the cerebellum by rTMS and inducing behavioral effects. This method of 'virtual lesions' can expand the study of the role of the cerebellum in motor control and cognition.

Transcranial magnetic stimulation: its current role in epilepsy research

This paper reviews the current role of transcranial magnetic stimulation (TMS) in epilepsy research. After a brief introduction to the technical principles, the physiology and the safety aspects of TMS, emphasis is put on how human cortex excitability can be assessed by TMS and how this may improve our understanding of pathophysiological mechanisms in epilepsy and the mode of action of antiepileptic drugs (AEDs). Also, potential therapeutical applications of TMS are reviewed. For all aspects of this paper, a clear distinction was made between single-/paired-pulse TMS and repetitive TMS, since these two techniques have fundamentally different scopes and applications.

Interactions between motor commands and somatic perception in sensorimotor cortex

For many years, it has been postulated that interactions between motor commands and somatic perception in the sensorimotor cortices exist, but they have been difficult to demonstrate. Recent studies have made demonstration of this interaction easier and suggest that cortical activity related to somatic sensation and perception is modified by movement-generating mechanisms. Corollary discharge and efference copy may also play a role in motor behavior.