Dorsal premotor cortex exerts state-dependent causal influences on activity in contralateral primary motor and dorsal premotor cortex

Dose-dependent target engagement of a clinical iTBS protocol: An interleaved TMS-fMRI study in healthy subjects

BACKGROUND

Intermittent theta burst stimulation (iTBS) of the dorsolateral prefrontal cortex (DLPFC) is widely applied as therapeutic intervention in mental health, however understanding of its mechanisms is still incomplete. Prior MRI studies have mainly used offline iTBS or short sequences in concurrent TMS-fMRI. This study investigated a full 600 stimuli iTBS protocol using interleaved TMS-fMRI in comparison with two control conditions in healthy subjects.

METHODS

In a crossover design, 18 participants underwent three sessions of interleaved iTBS-fMRI: 1) left DLPFC at 40% resting motor threshold (rMT) intensity, 2) left DLPFC at 80% rMT intensity, and 3) left primary motor cortex (M1) at 80% rMT intensity. We compared immediate blood-oxygen-level-dependent (BOLD) responses during interleaved iTBS-fMRI across these conditions including correlations between individual fMRI BOLD activation and iTBS induced electric field (E-field) strength at the target sites.

RESULTS

Whole-brain analysis showed increased activation in several regions following iTBS. Specifically, left DLPFC, as well as bilateral M1, anterior cingulate cortex, and insula showed increased activation during 80% rMT left DLPFC stimulation. Increased BOLD activity in the left DLPFC was not observed with 40% rMT left DLPFC stimulation nor left M1 80% rMT iTBS, whereas activation in other regions was found to overlap between conditions. Of note, BOLD activation and E-field intensities were only correlated for M1 stimulation, but not for the DLPFC conditions.

CONCLUSIONS

The study showed dosage and target specific BOLD activation during interleaved TMS-fMRI with 600 stimuli iTBS in healthy subjects. Future studies may use our approach for demonstrating target engagement.

Psychodynamically Informed Brain Stimulation: Building a Bridge from Brain to Mind

Since its inception, psychiatry has undergone several periods of radical identity transformation. Initially limited to psychotherapy alone, the advent of medications stimulated an era of biological psychiatry. For years, medications served as the mainstay of biological treatments, paralleled by a rise in treatment resistance. Brain stimulation therapies are psychiatry's newest arm of intervention and represent an area ripe for exploration. These techniques offer new hope to treatment-resistant patients, but in a manner often dissociated from psychoanalytic conceptualization and the practice of psychotherapy. There is growing interest in bridging this divide. In this article, we continue the efforts at interweaving what may seem to be disparate approaches through the topic of treatment resistance. This article aims to engage interventional psychiatrists in considering psychosocial dimensions of their treatments and to provide education for psychoanalytic clinicians on the history, mechanism of action, and applications of brain stimulation technologies.

Chronometric TMS-fMRI of personalized left dorsolateral prefrontal target reveals state-dependency of subgenual anterior cingulate cortex effects

Transcranial magnetic stimulation (TMS) applied to a left dorsolateral prefrontal cortex (DLPFC) area with a specific connectivity profile to the subgenual anterior cingulate cortex (sgACC) has emerged as a highly effective non-invasive treatment option for depression. However, antidepressant outcomes demonstrate significant variability among therapy plans and individuals. One overlooked contributing factor is the individual brain state at the time of treatment. In this study we used interleaved TMS-fMRI to investigate the influence of brain state on acute TMS effects, both locally and remotely. TMS was performed during rest and during different phases of cognitive task processing. Twenty healthy participants were included in this study. In the first session, imaging data for TMS targeting were acquired, allowing for identification of individualized targets in the left DLPFC based on highest anti-correlation with the sgACC. The second session involved chronometric interleaved TMS-fMRI measurements, with 10 Hz triplets of TMS administered during rest and at distinct timings during an N-back task. Consistent with prior findings, interleaved TMS-fMRI revealed significant BOLD activation changes in the targeted network. The precise timing of TMS relative to the cognitive states during the task demonstrated distinct BOLD response in clinically relevant brain regions, including the sgACC. Employing a standardized timing approach for TMS using a task revealed more consistent modulation of the sgACC at the group level compared to stimulation during rest. In conclusion, our findings strongly suggest that acute local and remote effects of TMS are influenced by brain state during stimulation. This study establishes a basis for considering brain state as a significant factor in designing treatment protocols, possibly improving TMS treatment outcomes.

Different Effect Sizes of Motor Skill Training Combined with Repetitive Transcranial versus Trans-Spinal Magnetic Stimulation in Healthy Subjects

Repetitive transcranial magnetic stimulation (rTMS) is used to enhance motor training (MT) performance. The use of rTMS is limited under certain conditions, such as after a stroke with severe damage to the corticospinal tract. This raises the question as to whether repetitive trans-spinal magnetic stimulation (rSMS) can also be used to improve MT. A direct comparison of the effect size between rTMS and rSMS on the same MT is still lacking. Before conducting the study in patients, we determined the effect sizes of different stimulation approaches combined with the same motor training in healthy subjects. Two experiments (E1 and E2) with 96 subjects investigated the effect size of combining magnetic stimulation with the same MT. In E1, high-frequency rTMS, rSMS, and spinal sham stimulation (sham-spinal) were applied once in combination with MT, while one group only received the same MT (without stimulation). In E2, rTMS, rSMS, and sham-spinal were applied in combination with MT over several days. In all subjects, motor tests and motor-evoked potentials were evaluated before and after the intervention period. rTMS had the greatest effect on MT, followed by rSMS and then sham-spinal. Daily stimulation resulted in additional training gains. This study suggests that rSMS increases excitability and also enhances MT performance. This current study provides a basis for further research to discover whether patients who cannot be treated effectively with rTMS would benefit from rSMS.

Lateral Prefrontal Stimulation of Active Cortex With Theta Burst Transcranial Magnetic Stimulation Affects Subsequent Engagement of the Frontoparietal Network

BACKGROUND

A critical unanswered question about therapeutic transcranial magnetic stimulation is what patients should do during treatment to optimize its effectiveness. Here, we address this lack of knowledge in healthy participants, testing the hypotheses that stimulating the left dorsolateral prefrontal cortex (dlPFC) while participants perform a working memory task will provide stronger effects on subsequent activation, perfusion, connectivity, and performance than stimulating resting dlPFC.

METHODS

After a baseline functional magnetic resonance imaging session to localize dlPFC activation and the associated frontoparietal network (FPN) engaged by an n-back task, healthy participants (N = 40, 67.5% female) underwent 3 counterbalanced sessions, separated by several weeks, during which they received intermittent theta burst stimulation (iTBS) followed by magnetic resonance imaging scans as follows: 1) iTBS to the dlPFC while resting passively (passive), 2) iTBS to the dlPFC while performing the n-back task (active), and 3) iTBS to a vertex site, while not engaged in the n-back task and resting passively (control).

RESULTS

We found no difference in n-back performance between the 3 conditions. However, FPN activation was reduced while performing the n-back task in the active condition relative to the passive and control conditions. There was no differential activity in the FPN on comparing passive with control conditions, i.e., there was no effect of the site of stimulation. We found no effects of state or site of stimulation on perfusion or connectivity with the dlPFC.

CONCLUSIONS

In this study, the state of the brain while receiving iTBS affected FPN activation, possibly reflecting greater efficiency of FPN network activation when participants were stimulated while engaging the FPN.

Converging Evidence for Frontopolar Cortex as a Target for Neuromodulation in Addiction Treatment

Noninvasive brain stimulation technologies such as transcranial electrical and magnetic stimulation (tES and TMS) are emerging neuromodulation therapies that are being used to target the neural substrates of substance use disorders. By the end of 2022, 205 trials of tES or TMS in the treatment of substance use disorders had been published, with heterogeneous results, and there is still no consensus on the optimal target brain region. Recent work may help clarify where and how to apply stimulation, owing to expanding databases of neuroimaging studies, new systematic reviews, and improved methods for causal brain mapping. Whereas most previous clinical trials targeted the dorsolateral prefrontal cortex, accumulating data highlight the frontopolar cortex as a promising therapeutic target for transcranial brain stimulation in substance use disorders. This approach is supported by converging multimodal evidence, including lesion-based maps, functional MRI-based maps, tES studies, TMS studies, and dose-response relationships. This review highlights the importance of targeting the frontopolar area and tailoring the treatment according to interindividual variations in brain state and trait and electric field distribution patterns. This converging evidence supports the potential for treatment optimization through context, target, dose, and timing dimensions to improve clinical outcomes of transcranial brain stimulation in people with substance use disorders in future clinical trials.

The behavioral and neural effects of parietal theta burst stimulation on the grasp network are stronger during a grasping task than at rest

Repetitive transcranial magnetic stimulation (TMS) is widely used in neuroscience and clinical settings to modulate human cortical activity. The effects of TMS on neural activity depend on the excitability of specific neural populations at the time of stimulation. Accordingly, the brain state at the time of stimulation may influence the persistent effects of repetitive TMS on distal brain activity and associated behaviors. We applied intermittent theta burst stimulation (iTBS) to a region in the posterior parietal cortex (PPC) associated with grasp control to evaluate the interaction between stimulation and brain state. Across two experiments, we demonstrate the immediate responses of motor cortex activity and motor performance to state-dependent parietal stimulation. We randomly assigned 72 healthy adult participants to one of three TMS intervention groups, followed by electrophysiological measures with TMS and behavioral measures. Participants in the first group received iTBS to PPC while performing a grasping task concurrently. Participants in the second group received iTBS to PPC while in a task-free, resting state. A third group of participants received iTBS to a parietal region outside the cortical grasping network while performing a grasping task concurrently. We compared changes in motor cortical excitability and motor performance in the three stimulation groups within an hour of each intervention. We found that parietal stimulation during a behavioral manipulation that activates the cortical grasping network increased downstream motor cortical excitability and improved motor performance relative to stimulation during rest. We conclude that constraining the brain state with a behavioral task during brain stimulation has the potential to optimize plasticity induction in cortical circuit mechanisms that mediate movement processes.

Prefrontal stimulation as a tool to disrupt hippocampal and striatal reactivations underlying fast motor memory consolidation

BACKGROUND

Recent evidence suggests that hippocampal replay in humans support rapid motor memory consolidation during epochs of wakefulness interleaved with task practice.

OBJECTIVES/HYPOTHESES

The goal of this study was to test whether such reactivation patterns can be modulated with experimental interventions and in turn influence fast consolidation. We hypothesized that non-invasive brain stimulation targeting hippocampal and striatal networks via the prefrontal cortex would influence brain reactivation and the rapid form of motor memory consolidation.

METHODS

Theta-burst stimulation was applied to a prefrontal cluster functionally connected to both the hippocampus and striatum of young healthy participants before they learned a motor sequence task in a functional magnetic resonance imaging (fMRI) scanner. Neuroimaging data acquired during task practice and the interleaved rest epochs were analyzed to comprehensively characterize the effect of stimulation on the neural processes supporting fast motor memory consolidation.

RESULTS

Our results collectively show that active, as compared to control, theta-burst stimulation of the prefrontal cortex hindered fast motor memory consolidation. Converging evidence from both univariate and multivariate analyses of fMRI data indicate that active stimulation disrupted hippocampal and caudate responses during inter-practice rest, presumably altering the reactivation of learning-related patterns during the micro-offline consolidation episodes. Last, stimulation altered the link between the brain and the behavioral markers of the fast consolidation process.

CONCLUSION

These results suggest that stimulation targeting deep brain regions via the prefrontal cortex can be used to modulate hippocampal and striatal reactivations in the human brain and influence motor memory consolidation.

Interhemispheric interplay between the left and right premotor cortex during grasping as assessed by dynamic causal modelling

Research on the contribution of the ipsilateral hemisphere to unilateral movements, and how it is mediated by transcallosal connections, has so far provided contradictory findings. By using dynamic causal modelling (DCM) and Parametric Empirical Bayes analyses applied to fMRI data, we sought to describe effective connectivity during pantomimed and imagined right-hand grasping within the grasping network, namely the anterior intraparietal sulcus, ventral and dorsal (PMd) premotor cortex, supplementary motor area and primary motor cortex (M1). The two-fold aim of the present work was to explore a) whether right and left parieto-frontal areas show similar connectivity couplings, and b) the interhemispheric dynamics between these regions across the two hemispheres. We detected a network architecture comparable across hemispheres during executed but not imagined grasping movements. Furthermore, during pantomimed grasping the interhemispheric crosstalk was mainly driven by premotor areas: we found an inhibitory influence from the right PMd toward the left premotor and motor areas and excitatory couplings between homologous ventral premotor and supplementary motor regions. Overall, our results support the view that dissociable components of unilateral grasping execution are encoded by a non-lateralized set of brain areas complexly intertwined by interhemispheric dynamics, whereas motor imagery obeys different principles.

Within-subject reliability of concurrent TMS-fMRI during a single session

Concurrent transcranial magnetic stimulation with functional MRI (concurrent TMS-fMRI) allows real-time causative probing of brain connectivity. However, technical challenges, safety, and tolerability may limit the number of trials employed during a concurrent TMS-fMRI experiment. We leveraged an existing data set with 100 trials of active TMS compared to a sub-threshold control condition to assess the reliability of the evoked BOLD response during concurrent TMS-fMRI. This data will permit an analysis of the minimum number of trials that should be employed in a concurrent TMS-fMRI protocol in order to achieve reliable spatial changes in activity. Single-subject maps of brain activity were created by splitting the trials within the same experimental session into groups of 50, 40, 30, 25, 20, 15, or 10 trials, correlations (R) between t-maps derived from paired subsets of trials within the same individual were calculated as reliability. R was moderate-high for 50 trials (mean R = .695) and decreased as the number of trials decreased. Consistent with previous findings of high individual variability in the spatial patterns of evoked neuronal changes following a TMS pulse, the spatial pattern of Rs differed across participants, but regional R was correlated with the magnitude of TMS-evoked activity. These results demonstrate concurrent TMS-fMRI produces a reliable pattern of activity at the individual level at higher trial numbers, particularly within localized regions. The spatial pattern of reliability is individually idiosyncratic and related to the individual pattern of evoked changes.

A guide for concurrent TMS-fMRI to investigate functional brain networks

Transcranial Magnetic Stimulation (TMS) allows for the direct activation of neurons in the human neocortex and has proven to be fundamental for causal hypothesis testing in cognitive neuroscience. By administering TMS concurrently with functional Magnetic Resonance Imaging (fMRI), the effect of cortical TMS on activity in distant cortical and subcortical structures can be quantified by varying the levels of TMS output intensity. However, TMS generates significant fluctuations in the fMRI time series, and their complex interaction warrants caution before interpreting findings. We present the methodological challenges of concurrent TMS-fMRI and a guide to minimize induced artifacts in experimental design and post-processing. Our study targeted two frontal-striatal circuits: primary motor cortex (M1) projections to the putamen and lateral prefrontal cortex (PFC) projections to the caudate in healthy human participants. We found that TMS parametrically increased the BOLD signal in the targeted region and subcortical projections as a function of stimulation intensity. Together, this work provides practical steps to overcome common challenges with concurrent TMS-fMRI and demonstrates how TMS-fMRI can be used to investigate functional brain networks.

An abstract categorical decision code in dorsal premotor cortex

The dorsal premotor cortex (DPC) has classically been associated with a role in preparing and executing the physical motor variables during cognitive tasks. While recent work has provided nuanced insights into this role, here we propose that DPC also participates more actively in decision-making. We recorded neuronal activity in DPC while two trained monkeys performed a vibrotactile categorization task, utilizing two partially overlapping ranges of stimulus values that varied on two physical attributes: vibrotactile frequency and amplitude. We observed a broad heterogeneity across DPC neurons, the majority of which maintained the same response patterns across attributes and ranges, coding in the same periods, mixing temporal and categorical dynamics. The predominant categorical signal was maintained throughout the delay, movement periods and notably during the intertrial period. Putting the entire population's data through two dimensionality reduction techniques, we found strong temporal and categorical representations without remnants of the stimuli's physical parameters. Furthermore, projecting the activity of one population over the population axes of the other yielded identical categorical and temporal responses. Finally, we sought to identify functional subpopulations based on the combined activity of all stimuli, neurons, and time points; however, we found that single-unit responses mixed temporal and categorical dynamics and couldn't be clustered. All these point to DPC playing a more decision-related role than previously anticipated.

Transcranial magnetic stimulation of the brain: What is stimulated? - A consensus and critical position paper

Transcranial (electro)magnetic stimulation (TMS) is currently the method of choice to non-invasively induce neural activity in the human brain. A single transcranial stimulus induces a time-varying electric field in the brain that may evoke action potentials in cortical neurons. The spatial relationship between the locally induced electric field and the stimulated neurons determines axonal depolarization. The induced electric field is influenced by the conductive properties of the tissue compartments and is strongest in the superficial parts of the targeted cortical gyri and underlying white matter. TMS likely targets axons of both excitatory and inhibitory neurons. The propensity of individual axons to fire an action potential in response to TMS depends on their geometry, myelination and spatial relation to the imposed electric field and the physiological state of the neuron. The latter is determined by its transsynaptic dendritic and somatic inputs, intrinsic membrane potential and firing rate. Modeling work suggests that the primary target of TMS is axonal terminals in the crown top and lip regions of cortical gyri. The induced electric field may additionally excite bends of myelinated axons in the juxtacortical white matter below the gyral crown. Neuronal excitation spreads ortho- and antidromically along the stimulated axons and causes secondary excitation of connected neuronal populations within local intracortical microcircuits in the target area. Axonal and transsynaptic spread of excitation also occurs along cortico-cortical and cortico-subcortical connections, impacting on neuronal activity in the targeted network. Both local and remote neural excitation depend critically on the functional state of the stimulated target area and network. TMS also causes substantial direct co-stimulation of the peripheral nervous system. Peripheral co-excitation propagates centrally in auditory and somatosensory networks, but also produces brain responses in other networks subserving multisensory integration, orienting or arousal. The complexity of the response to TMS warrants cautious interpretation of its physiological and behavioural consequences, and a deeper understanding of the mechanistic underpinnings of TMS will be critical for advancing it as a scientific and therapeutic tool.

The effects of TMS over the anterior intraparietal area on anticipatory fingertip force scaling and the size-weight illusion

When lifting an object skillfully, fingertip forces need to be carefully scaled to the object's weight, which can be inferred from its apparent size and material. This anticipatory force scaling ensures smooth and efficient lifting movements. However, even with accurate motor plans, weight perception can still be biased. In the size-weight illusion, objects of different size but equal weight are perceived to differ in heaviness, with the small object perceived to be heavier than the large object. The neural underpinnings of anticipatory force scaling to object size and the size-weight illusion are largely unknown. In this study, we tested the role of anterior intraparietal cortex (aIPS) in predictive force scaling and the size-weight illusion, by applying continuous theta burst stimulation (cTBS) prior to participants lifting objects of different sizes. Participants received cTBS over aIPS, the primary motor cortex (control area), or Sham stimulation. We found no evidence that aIPS stimulation affected the size-weight illusion. Effects were, however, found on anticipatory force scaling, where grip force was less tuned to object size during initial lifts. These findings suggest that aIPS is not involved in the perception of object weight but plays a transient role in the sensorimotor predictions related to object size. NEW & NOTEWORTHY Skilled object manipulation requires forming anticipatory motor plans according to the object's properties. Here, we demonstrate the role of anterior intraparietal sulcus (aIPS) in anticipatory grip force scaling to object size, particularly during initial lifting experience. Interestingly, this role was not maintained after continued practice and was not related to perceptual judgments measured with the size-weight illusion.

Effect of behavioral practice targeted at the motor action selection network after stroke

Motor action selection engages a network of frontal and parietal brain regions. After stroke, individuals activate a similar network, however, activation is higher, especially in the contralesional hemisphere. The current study examined the effect of practice on action selection performance and brain activation after stroke. Sixteen individuals with chronic stroke (Upper Extremity Fugl-Meyer motor score range: 18-61) moved a joystick with the more-impaired hand in two conditions: Select (externally cued choice; move right or left based on an abstract rule) and Execute (simple response; move same direction every trial). On Day 1, reaction time (RT) was longer in Select compared to Execute which corresponded to increased activation primarily in regions in the contralesional action selection network including dorsal premotor, supplementary motor, anterior cingulate and parietal cortices. After four days of practice, behavioral performance improved (decreased RT) and only contralesional parietal cortex significantly increased during Select. Higher brain activation on Day 1 in the bilateral action selection network, dorsolateral prefrontal cortex, and contralesional sensory cortex predicted better performance on Day 4. Overall, practice led to improved action selection performance and reduced brain activation. Systematic changes in practice conditions may allow the targeting of specific components of the motor network during rehabilitation after stroke.

TMS Does Not Increase BOLD Activity at the Site of Stimulation: A Review of All Concurrent TMS-fMRI Studies

Transcranial magnetic stimulation (TMS) is widely used for understanding brain function in neurologically intact subjects and for the treatment of various disorders. However, the precise neurophysiological effects of TMS at the site of stimulation remain poorly understood. The local effects of TMS can be studied using concurrent TMS-functional magnetic resonance imaging (fMRI), a technique where TMS is delivered during fMRI scanning. However, although concurrent TMS-fMRI was developed over 20 years ago and dozens of studies have used this technique, there is still no consensus on whether TMS increases blood oxygen level-dependent (BOLD) activity at the site of stimulation. To address this question, here we review all previous concurrent TMS-fMRI studies that reported analyses of BOLD activity at the target location. We find evidence that TMS increases local BOLD activity when stimulating the primary motor (M1) and visual (V1) cortices but that these effects are likely driven by the downstream consequences of TMS (finger twitches and phosphenes). However, TMS does not appear to increase BOLD activity at the site of stimulation for areas outside of the M1 and V1 when conducted at rest. We examine the possible reasons for such lack of BOLD signal increase based on recent work in nonhuman animals. We argue that the current evidence points to TMS inducing periods of increased and decreased neuronal firing that mostly cancel each other out and therefore lead to no change in the overall BOLD signal.

Concurrent frontal and parietal network TMS for modulating attention

Transcranial magnetic stimulation (TMS) has been applied to frontal eye field (FEF) and intraparietal sulcus (IPS) in isolation, to study their role in attention. However, these nodes closely interact in a "dorsal attention network". Here, we compared effects of inhibitory TMS applied to individually fMRI-localized FEF or IPS (single-node TMS), to effects of simultaneously inhibiting both regions ("network TMS"), and sham. We assessed attention performance using the lateralized attention network test, which captures multiple facets of attention: spatial orienting, alerting, and executive control. TMS showed no effects on alerting and executive control. For spatial orienting, only network TMS showed a reduction of the orienting effect in the right hemifield compared to the left hemifield, irrespective of the order of TMS application (IPS→FEF or FEF→IPS). Network TMS might prevent compensatory mechanisms within a brain network, which is promising for both research and clinical applications to achieve superior neuromodulation effects.

Tools to explore neuroplasticity in humans: Combining interventional neurophysiology with functional and structural magnetic resonance imaging and spectroscopy

This chapter summarizes how brain imaging can be used in combination with non-invasive transcranial stimulation to probe and induce neuroplasticity in the human brain. We aim to give a conceptual account and highlight exemplary studies. We showcase the scientific and clinical potentials of studies focusing on the combination of transcranial magnetic stimulation (TMS) with Magnetic Resonance Imaging (MRI) or Magnetic Resonance Spectroscopy (MRS). MRI and MRS can be used before brain stimulation to identify target networks and loci but also to inform individual dosing. After a brain stimulation session, MRI and MRS can be used to pinpoint how the stimulation protocol alters brain function, structure, or metabolism and relate these after-effects to behavioral and clinical outcomes. Complementing these "offline" approaches, TMS can also be applied "online" during MRI or MRS to delineate how stimulation acutely engages the stimulated brain regions and networks. In this case, it is critical to account for confounds introduced by off-target stimulation of peripheral structures of the nervous system that may not only confound MR-based readouts but also induce neuroplastic phenomena.

Concurrent TMS-fMRI: Technical Challenges, Developments, and Overview of Previous Studies

Transcranial magnetic stimulation (TMS) is a promising treatment modality for psychiatric and neurological disorders. Repetitive TMS (rTMS) is widely used for the treatment of psychiatric and neurological diseases, such as depression, motor stroke, and neuropathic pain. However, the underlying mechanisms of rTMS-mediated neuronal modulation are not fully understood. In this respect, concurrent or simultaneous TMS-fMRI, in which TMS is applied during functional magnetic resonance imaging (fMRI), is a viable tool to gain insights, as it enables an investigation of the immediate effects of TMS. Concurrent application of TMS during neuroimaging usually causes severe artifacts due to magnetic field inhomogeneities induced by TMS. However, by carefully interleaving the TMS pulses with MR signal acquisition in the way that these are far enough apart, we can avoid any image distortions. While the very first feasibility studies date back to the 1990s, recent developments in coil hardware and acquisition techniques have boosted the number of TMS-fMRI applications. As such, a concurrent application requires expertise in both TMS and MRI mechanisms and sequencing, and the hurdle of initial technical set up and maintenance remains high. This review gives a comprehensive overview of concurrent TMS-fMRI techniques by collecting (1) basic information, (2) technical challenges and developments, (3) an overview of findings reported so far using concurrent TMS-fMRI, and (4) current limitations and our suggestions for improvement. By sharing this review, we hope to attract the interest of researchers from various backgrounds and create an educational knowledge base.

Chemogenetic sensory fMRI reveals behaviorally relevant bidirectional changes in primate somatosensory network

Concurrent genetic neuromodulation and functional magnetic resonance imaging (fMRI) in primates has provided a valuable opportunity to assess the modified brain-wide operation in the resting state. However, its application to link the network operation with behavior still remains challenging. Here, we combined chemogenetic silencing of the primary somatosensory cortex (SI) with tactile fMRI and related behaviors in macaques. Focal chemogenetic silencing of functionally identified SI hand region impaired grasping behavior. The same silencing also attenuated hand stimulation-evoked fMRI signal at both the local silencing site and the anatomically and/or functionally connected downstream grasping network, suggesting altered network operation underlying the induced behavioral impairment. Furthermore, the hand region silencing unexpectedly disinhibited foot representation with accompanying behavioral hypersensitization. These results demonstrate that focal chemogenetic silencing with sensory fMRI in macaques unveils bidirectional network changes to generate multifaceted behavioral impairments, thereby opening a pivotal window toward elucidating the causal network operation underpinning higher brain functions in primates.

Exploring cortico-cortical interactions during action preparation by means of dual-coil transcranial magnetic stimulation: A systematic review

Action preparation is characterized by a set of complex and distributed processes that occur in multiple brain areas. Interestingly, dual-coil transcranial magnetic stimulation (TMS) is a relevant technique to probe effective connectivity between cortical areas, with a high temporal resolution. In the current systematic review, we aimed at providing a detailed picture of the cortico-cortical interactions underlying action preparation focusing on dual-coil TMS studies. We considered four theoretical processes (impulse control, action selection, movement initiation and action reprogramming) and one task modulator (movement complexity). The main findings highlight 1) the interplay between primary motor cortex (M1) and premotor, prefrontal and parietal cortices during action preparation, 2) the varying (facilitatory or inhibitory) cortico-cortical influence depending on the theoretical processes and the TMS timing, and 3) the key role of the supplementary motor area-M1 interactions that shape the preparation of simple and complex movements. These findings are of particular interest for clinical perspectives, with a need to better characterize functional connectivity deficiency in clinical population with altered action preparation.

Concurrent neuroimaging and neurostimulation reveals a causal role for dlPFC in coding of task-relevant information

Dorsolateral prefrontal cortex (dlPFC) is proposed to drive brain-wide focus by biasing processing in favour of task-relevant information. A longstanding debate concerns whether this is achieved through enhancing processing of relevant information and/or by inhibiting irrelevant information. To address this, we applied transcranial magnetic stimulation (TMS) during fMRI, and tested for causal changes in information coding. Participants attended to one feature, whilst ignoring another feature, of a visual object. If dlPFC is necessary for facilitation, disruptive TMS should decrease coding of attended features. Conversely, if dlPFC is crucial for inhibition, TMS should increase coding of ignored features. Here, we show that TMS decreases coding of relevant information across frontoparietal cortex, and the impact is significantly stronger than any effect on irrelevant information, which is not statistically detectable. This provides causal evidence for a specific role of dlPFC in enhancing task-relevant representations and demonstrates the cognitive-neural insights possible with concurrent TMS-fMRI-MVPA.

Transcranial magnetic stimulation alters multivoxel patterns in the absence of overall activity changes

Transcranial magnetic stimulation (TMS) has become one of the major tools for establishing the causal role of specific brain regions in perceptual, motor, and cognitive processes. Nevertheless, a persistent limitation of the technique is the lack of clarity regarding its precise effects on neural activity. Here, we examined the effects of TMS intensity and frequency on concurrently recorded blood‐oxygen‐level‐dependent (BOLD) signals at the site of stimulation. In two experiments, we delivered TMS to the dorsolateral prefrontal cortex in human subjects of both sexes. In Experiment 1, we delivered a series of pulses at high (100% of motor threshold) or low (50% of motor threshold) intensity, whereas, in Experiment 2, we always used high intensity but delivered stimulation at four different frequencies (5, 8.33, 12.5, and 25 Hz). We found that the TMS intensity and frequency could be reliably decoded using multivariate analysis techniques even though TMS had no effect on the overall BOLD activity at the site of stimulation in either experiment. These results provide important insight into the mechanisms through which TMS influences neural activity.

Unravelling Ipsilateral Interactions Between Left Dorsal Premotor and Primary Motor Cortex: A Proof of Concept Study

Few studies have identified the intrahemispheric functional connectivity between the ipsilateral dorsal premotor cortex (PMd) and the primary motor hand area (M1_hand) due to technical limitations. In this proof-of-concept study, a novel neuronavigated dsTMS set-up was employed, combining stimulation over left PMd and left M1_hand using the edge of a butterfly coil and a small cooled-coil. This arrangement was warranted because coil (over)heating and inter coil distance are limiting factors when investigating connectivity between stimulation targets in close proximity and over a longer duration. The proposed set-up was designed to deal with these limitations. Specifically, the effect of four dual-site transcranial magnetic stimulation (dsTMS) protocols on twenty-eight right-handed participants (12 males) was evaluated. These protocols differed in stimulus order, interstimulus interval and current direction induced in PMd. A structural scan with electric (E-)field modeling was obtained from seven participants prior to dsTMS, demonstrating that PMd and M1_hand were effectively stimulated. Results indicate that one protocol, in which a latero-medial current was induced in PMd 2.8 ms prior to stimulation over M1_hand, induced a sex-mediated effect. In males, significant inhibition of motor-evoked potentials was identified, whereas females demonstrated a facilitatory effect that did not survive correction for multiple comparisons. E-field simulations revealed that the E-field induced by the coil targeting PMd was maximal in PMd, with weaker E-field strengths extending to regions beyond PMd. Summarizing, the current dsTMS set-up enabled stimulating at an inter-target distance of 35 mm without any indications of coil-overheating.

Concurrent TMS-fMRI for causal network perturbation and proof of target engagement

The experimental manipulation of neural activity by neurostimulation techniques overcomes the inherent limitations of correlative recordings, enabling the researcher to investigate causal brain-behavior relationships. But only when stimulation and recordings are combined, the direct impact of the stimulation on neural activity can be evaluated. In humans, this can be achieved non-invasively through the concurrent combination of transcranial magnetic stimulation (TMS) with functional magnetic resonance imaging (fMRI). Concurrent TMS-fMRI allows the assessment of the neurovascular responses evoked by TMS with excellent spatial resolution and full-brain coverage. This enables the functional mapping of both local and remote network effects of TMS in cortical as well as deep subcortical structures, offering unique opportunities for basic research and clinical applications. The purpose of this review is to introduce the reader to this powerful tool. We will introduce the technical challenges and state-of-the art solutions and provide a comprehensive overview of the existing literature and the available experimental approaches. We will highlight the unique insights that can be gained from concurrent TMS-fMRI, including the state-dependent assessment of neural responsiveness and inter-regional effective connectivity, the demonstration of functional target engagement, and the systematic evaluation of stimulation parameters. We will also discuss how concurrent TMS-fMRI during a behavioral task can help to link behavioral TMS effects to changes in neural network activity and to identify peripheral co-stimulation confounds. Finally, we will review the use of concurrent TMS-fMRI for developing TMS treatments of psychiatric and neurological disorders and suggest future improvements for further advancing the application of concurrent TMS-fMRI.

Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: Recent Critical Advances in Patient Care

PURPOSE

Transcranial magnetic stimulation (TMS) is an evidence-based treatment for pharmacoresistant major depressive disorder (MDD). In the last decade, the field has seen significant advances in the understanding and use of this new technology. This review aims to describe the large, randomized controlled studies leading to the modern use of rTMS for MDD. It also includes a special section briefly discussing the use of these technologies during the COVID-19 pandemic.

RECENT FINDINGS

Several new approaches and technologies are emerging in this field, including novel approaches to reduce treatment time and potentially yield new approaches to optimize and maximize clinical outcomes. Of these, theta burst TMS now has evidence indicating it is non-inferior to standard TMS and provides significant advantages in administration. Recent studies also indicate that neuroimaging and related approaches may be able to improve TMS targeting methods and potentially identify those patients most likely to respond to stimulation.

SUMMARY

While new data is promising, significant research remains to be done to individualize and optimize TMS procedures. Emerging new approaches, such as accelerated TMS and advanced targeting methods, require additional replication and demonstration of real-world clinical utility. Cautious administration of TMS during the pandemic is possible with careful attention to safety procedures.

Upregulation of Supplementary Motor Area Activation with fMRI Neurofeedback during Motor Imagery

Functional magnetic resonance imaging (fMRI) neurofeedback (NF) is a promising tool to study the relationship between behavior and brain activity. It enables people to self-regulate their brain signal. Here, we applied fMRI NF to train healthy participants to increase activity in their supplementary motor area (SMA) during a motor imagery (MI) task of complex body movements while they received a continuous visual feedback signal. This signal represented the activity of participants’ localized SMA regions in the NF group and a prerecorded signal in the control group (sham feedback). In the NF group only, results showed a gradual increase in SMA-related activity across runs. This upregulation was largely restricted to the SMA, while other regions of the motor network showed no, or only marginal NF effects. In addition, we found behavioral changes, i.e., shorter reaction times in a Go/No-go task after the NF training only. These results suggest that NF can assist participants to develop greater control over a specifically targeted motor region involved in motor skill learning. The results contribute to a better understanding of the underlying mechanisms of SMA NF based on MI with a direct implication for rehabilitation of motor dysfunctions.

Causal Inferences in Repetitive Transcranial Magnetic Stimulation Research: Challenges and Perspectives

Transcranial magnetic stimulation (TMS) is used to make inferences about relationships between brain areas and their functions because, in contrast to neuroimaging tools, it modulates neuronal activity. The central aim of this article is to critically evaluate to what extent it is possible to draw causal inferences from repetitive TMS (rTMS) data. To that end, we describe the logical limitations of inferences based on rTMS experiments. The presented analysis suggests that rTMS alone does not provide the sort of premises that are sufficient to warrant strong inferences about the direct causal properties of targeted brain structures. Overcoming these limitations demands a close look at the designs of rTMS studies, especially the methodological and theoretical conditions which are necessary for the functional decomposition of the relations between brain areas and cognitive functions. The main points of this article are that TMS-based inferences are limited in that stimulation-related causal effects are not equivalent to structure-related causal effects due to TMS side effects, the electric field distribution, and the sensitivity of neuroimaging and behavioral methods in detecting structure-related effects and disentangling them from confounds. Moreover, the postulated causal effects can be based on indirect (network) effects. A few suggestions on how to manage some of these limitations are presented. We discuss the benefits of combining rTMS with neuroimaging in experimental reasoning and we address the restrictions and requirements of rTMS control conditions. The use of neuroimaging and control conditions allows stronger inferences to be gained, but the strength of the inferences that can be drawn depends on the individual experiment's designs. Moreover, in some cases, TMS might not be an appropriate method of answering causality-related questions or the hypotheses have to account for the limitations of this technique. We hope this summary and formalization of the reasoning behind rTMS research can be of use not only for scientists and clinicians who intend to interpret rTMS results causally but also for philosophers interested in causal inferences based on brain stimulation research.

Transcranial Magnetic Stimulation Over the Human Medial Posterior Parietal Cortex Disrupts Depth Encoding During Reach Planning

Accumulating evidence supports the view that the medial part of the posterior parietal cortex (mPPC) is involved in the planning of reaching, but while plenty of studies investigated reaching performed toward different directions, only a few studied different depths. Here, we investigated the causal role of mPPC (putatively, human area V6A-hV6A) in encoding depth and direction of reaching. Specifically, we applied single-pulse transcranial magnetic stimulation (TMS) over the left hV6A at different time points while 15 participants were planning immediate, visually guided reaching by using different eye-hand configurations. We found that TMS delivered over hV6A 200 ms after the Go signal affected the encoding of the depth of reaching by decreasing the accuracy of movements toward targets located farther with respect to the gazed position, but only when they were also far from the body. The effectiveness of both retinotopic (farther with respect to the gaze) and spatial position (far from the body) is in agreement with the presence in the monkey V6A of neurons employing either retinotopic, spatial, or mixed reference frames during reach plan. This work provides the first causal evidence of the critical role of hV6A in the planning of visually guided reaching movements in depth.

Involvement of the primary motor cortex in the early processing stage of the affective stimulus-response compatibility effect in a manikin task

Compatible (positive approaching and negative avoiding) and incompatible (positive avoiding and negative approaching) behavior are of great significance for biological adaptation and survival. Previous research has found that reaction times of compatible behavior are shorter than the incompatible behavior, which is termed the stimulus-response compatibility (SRC) effect. However, the underlying neurophysiological mechanisms of the SRC effect applied to affective stimuli is still unclear. Here, we investigated preparatory activities in both the left and right primary motor cortex (M1) before the execution of an approaching-avoiding behavior using the right index finger in a manikin task based on self-identity. The results showed significantly shorter reaction times for compatible than incompatible behavior. Most importantly, motor-evoked potential (MEP) amplitudes from left M1 stimulation were significantly higher during compatible behavior than incompatible behavior at 150 and 200 ms after stimulus presentation, whereas the reversed was observed for right M1 stimulation with lower MEP amplitude in compatible compared to incompatible behavior at 150 ms. The current findings revealed the compatibility effect at both behavioral and neurophysiological levels, indicating that the affective SRC effect occurs early in the motor cortices during stimulus processing, and MEP modulation at this early processing stage could be a physiological marker of the affective SRC effect.

Inferring Causality from Noninvasive Brain Stimulation in Cognitive Neuroscience

Noninvasive brain stimulation (NIBS) techniques, such as transcranial magnetic stimulation or transcranial direct and alternating current stimulation, are advocated as measures to enable causal inference in cognitive neuroscience experiments. Transcending the limitations of purely correlative neuroimaging measures and experimental sensory stimulation, they allow to experimentally manipulate brain activity and study its consequences for perception, cognition, and eventually, behavior. Although this is true in principle, particular caution is advised when interpreting brain stimulation experiments in a causal manner. Research hypotheses are often oversimplified, disregarding the underlying (implicitly assumed) complex chain of causation, namely, that the stimulation technique has to generate an electric field in the brain tissue, which then evokes or modulates neuronal activity both locally in the target region and in connected remote sites of the network, which in consequence affects the cognitive function of interest and eventually results in a change of the behavioral measure. Importantly, every link in this causal chain of effects can be confounded by several factors that have to be experimentally eliminated or controlled to attribute the observed results to their assumed cause. This is complicated by the fact that many of the mediating and confounding variables are not directly observable and dose-response relationships are often nonlinear. We will walk the reader through the chain of causation for a generic cognitive neuroscience NIBS study, discuss possible confounds, and advise appropriate control conditions. If crucial assumptions are explicitly tested (where possible) and confounds are experimentally well controlled, NIBS can indeed reveal cause-effect relationships in cognitive neuroscience studies.

The role of the PMd in task complexity: functional connectivity is modulated by motor learning and age

The dorsal premotor cortex (PMd) plays a key role in the control and learning of motor tasks, especially when task complexity is high. This study sought to investigate the effect of task complexity on PMd-seeded functional connectivity in the context of aging using psychophysiological interaction analyses. Young and older participants were enrolled in a 3-day training protocol whereby task-related functional magnetic resonance imaging data were acquired. During training, movement was either internally generated or externally generated in the absence or presence of online visual feedback, respectively. Behavioral results indicated that older adults tended to have more difficulties with the complex task variants as compared with young adults. On a neural level, older adults demonstrated difficulties in flexibly adjusting their neural resources dependent on the feedback provided. Furthermore, PMd-seeded connectivity was related to a behavioral task complexity index in both age groups, albeit mediated by age. Together, these results highlight the importance of PMd in adaptability to task complexity and its age-related effects.

Modulating Brain Networks With Transcranial Magnetic Stimulation Over the Primary Motor Cortex: A Concurrent TMS/fMRI Study

Stimulating the primary motor cortex (M1) using transcranial magnetic stimulation (TMS) causes unique multisensory experience such as the targeted muscle activity, afferent/reafferent sensory feedback, tactile sensation over the scalp and “click” sound. Although the human M1 has been intensively investigated using TMS, the experience of the M1 stimulation has not been elucidated at the whole brain. Here, using concurrent TMS/fMRI, we investigated the acute effect of the M1 stimulation of functional brain networks during task and at rest. A short train of 1 Hz TMS pulses applied to individuals’ hand area in the M1 during motor execution or at rest. Employing the independent component analysis (ICA), we showed the M1 stimulation decreased the motor networks activity when the networks were engaged in the task and increased the deactivation of networks when the networks were not involved in the ongoing task. The M1 stimulation induced the activation in the key networks involved in bodily self-consciousness (BSC) including the insular and rolandic operculum systems regardless of states. The degree of activation in these networks was prominent at rest compared to task conditions, showing the state-dependent TMS effect. Furthermore, we demonstrated that the M1 stimulation modulated other domain-general networks such as the default mode network (DMN) and attention network and the inter-network connectivity between these networks. Our results showed that the M1 stimulation induced the widespread changes in the brain at the targeted system as well as non-motor, remote brain networks, specifically related to the BSC. Our findings shed light on understanding the neural mechanism of the complex and multisensory experience of the M1 stimulation.

Theta Burst Transcranial Magnetic Stimulation of Fronto-Parietal Networks: Modulation by Mental State

Transcranial magnetic stimulation (TMS) treats neuropsychiatric disorders, but effects of stimulation are highly state-dependent and in most therapeutic applications, mental state is not controlled. This exploratory proposal will test the broad hypothesis that when TMS, specifically intermittent theta burst stimulation (iTBS), is applied during a controlled mental state, network changes will be facilitated, compared to stimulation when mental state is uncontrolled. We will focus on the dorsolateral prefrontal cortex (dlPFC) and the associated fronto-parietal network (FPN), which subserves cognitive control, an important neural and behavioral target of therapeutic TMS. After a baseline functional magnetic resonance imaging (fMRI) session, iTBS will be administered to 40 healthy subjects in three sessions over three days in a within-subjects, cross-over design: (1) dlPFC stimulation by iTBS alone, (2) dlPFC stimulation by iTBS while simultaneously performing a cognitive task, and (3) vertex (control) iTBS stimulation. Immediately after each iTBS session, we will measure blood oxygenation level-dependent (BOLD) activation during a cognitive control task (“n-back” task) and during the resting state, using BOLD connectivity and arterial spin labeling (ASL). We will test hypotheses that persisting neural changes and performance enhancement induced by iTBS to the dlPFC, compared to iTBS to the vertex, will affect the FPN, and these effects will be modulated by whether or not subjects receive iTBS when they are engaged in a cognitive control task. Demonstrating this interaction between iTBS and mental state will lay critical groundwork for future studies to show how controlling mental state during TMS can improve therapeutic effects.

Acquisition of chopstick-operation skills with the non-dominant hand and concomitant changes in brain activity

Despite their common use as eating utensils in East Asia, chopsticks require complex fine motor-skills for adequate operation and are thus most frequently used with the dominant hand; however, the effect of training time on the proficiency of using chopsticks with the non-dominant hand, as well as the brain activity underlying changes in skill, remain unclear. This study characterised the effect of time spent training in chopstick operation with the non-dominant hand on chopstick-use proficiency and the related brain activity to obtain data that may help individuals who are obliged to change handedness due to neurological disease to learn to use their non-dominant hand in performing daily activities. Thirty-two healthy right-handed students were randomly allocated to training (n = 16) or control (n = 16) groups; the former received 6 weeks of training in chopstick use with their non-dominant (left) hand, and the latter received none. After training, significant improvements in the execution speed and smoothness of upper extremity joints were observed in the training group. Moreover, left dorsolateral prefrontal cortex activity significantly decreased, and bilateral premotor cortex activity significantly increased across training. These results indicated that 6 weeks of chopstick training with the non-dominant hand effectively improved chopstick operation.

Hippocampal connectivity with sensorimotor cortex during volitional finger movements: Laterality and relationship to motor learning

Hippocampal interactions with the motor system are often assumed to reflect the role of memory in motor learning. Here, we examine hippocampal connectivity with sensorimotor cortex during two tasks requiring paced movements, one with a mnemonic component (sequence learning) and one without (repetitive tapping). Functional magnetic resonance imaging activity was recorded from thirteen right-handed subjects; connectivity was identified from sensorimotor cortex correlations with psychophysiological interactions in hippocampal activity between motor and passive visual tasks. Finger movements in both motor tasks anticipated the timing of the metronome, reflecting cognitive control, yet evidence of motor learning was limited to the sequence learning task; nonetheless, hippocampal connectivity was observed during both tasks. Connectivity from corresponding regions in the left and right hippocampus overlapped extensively, with improved sensitivity resulting from their conjunctive (global) analysis. Positive and negative connectivity were both evident, with positive connectivity in sensorimotor cortex ipsilateral to the moving hand during unilateral movements, whereas negative connectivity was prominent in whichever hemisphere was most active during movements. Results implicate the hippocampus in volitional finger movements even in the absence of motor learning or recall.

Neural effects of transcranial magnetic stimulation at the single-cell level

Transcranial magnetic stimulation (TMS) can non-invasively modulate neural activity in humans. Despite three decades of research, the spatial extent of the cortical area activated by TMS is still controversial. Moreover, how TMS interacts with task-related activity during motor behavior is unknown. Here, we applied single-pulse TMS over macaque parietal cortex while recording single-unit activity at various distances from the center of stimulation during grasping. The spatial extent of TMS-induced activation is remarkably restricted, affecting the spiking activity of single neurons in an area of cortex measuring less than 2 mm in diameter. In task-related neurons, TMS evokes a transient excitation followed by reduced activity, paralleled by a significantly longer grasping time. Furthermore, TMS-induced activity and task-related activity do not summate in single neurons. These results furnish crucial experimental evidence for the neural effects of TMS at the single-cell level and uncover the neural underpinnings of behavioral effects of TMS.

Transcranial Magnetic Stimulation (TMS) can modulate human brain activity, but the extent of the cortical area activated by TMS is unclear. Here, the authors show that TMS affects monkey single neuron activity in an area less than 2 mm diameter, while TMS-induced activity and task-related activity do not summate.

Maturation changes the excitability and effective connectivity of the frontal lobe: A developmental TMS-EEG study

The combination of transcranial magnetic stimulation with simultaneous electroencephalography (TMS-EEG) offers direct neurophysiological insight into excitability and connectivity within neural circuits. However, there have been few developmental TMS-EEG studies to date, and they all have focused on primary motor cortex stimulation. In the present study, we used navigated high-density TMS-EEG to investigate the maturation of the superior frontal cortex (dorsal premotor cortex [PMd]), which is involved in a broad range of motor and cognitive functions known to develop with age. We demonstrated that reactivity to frontal cortex TMS decreases with development. We also showed that although frontal cortex TMS elicits an equally complex TEP waveform in all age groups, the statistically significant between-group differences in the topography of the TMS-evoked peaks and differences in current density maps suggest changes in effective connectivity of the right PMd with maturation. More generally, our results indicate that direct study of the brain's excitability and effective connectivity via TMS-EEG co-registration can also be applied to pediatric populations outside the primary motor cortex, and may provide useful information for developmental studies and studies on developmental neuropsychiatric disorders.

Mapping Structure-Function Relationships in the Brain

Mapping the structural and functional connectivity of the brain is a major focus of systems neuroscience research and will help to identify causally important changes in neural circuitry responsible for behavioral dysfunction. Several methods for examining brain activity in humans have been extended to rodent and monkey models in which molecular and genetic manipulations exist for linking to human disease. In this review, which is part of a special issue focused on bridging brain connectivity information across species and spatiotemporal scales, we address mapping brain activity and neural connectivity in rodents using optogenetics in conjunction with either functional magnetic resonance imaging or optical intrinsic signal imaging. We chose to focus on these techniques because they are capable of reporting spontaneous or evoked hemodynamic activity most closely linked to human neuroimaging studies. We discuss the capabilities and limitations of blood-based imaging methods, usage of optogenetic techniques to map neural systems in rodent models, and other powerful mapping techniques for examining neural connectivity over different spatial and temporal scales. We also discuss implementing strategies for mapping brain connectivity in humans with both basic and clinical applications, and conclude with how cross-species mapping studies can be utilized to influence preclinical imaging studies and clinical practices alike.

The Dynamic Duo: Combining noninvasive brain stimulation with cognitive interventions

Pharmacotherapy, psychotherapy, and non-invasive brain stimulation (NIBS)¹ each show efficacy in the treatment of psychiatric disorders; however, more efficacious interventions are needed as reflected by an overall unmet need in mental health care. While each modality has typically been studied and developed as a monotherapy, in practice they are typically used in combination. Research has begun to emerge studying the potential synergistic actions of multi-modal, combination therapies. For example, NIBS combined with rehabilitation strategies have demonstrated some success for speech and motor rehabilitation in stroke patients. In this review we present evidence suggesting that combining NIBS with targeted, cognitive interventions offers a potentially powerful new approach to treating neuropsychiatric disorders. Here we focus on NIBS studies using transcranial direct current stimulation (tDCS)² and transcranial magnetic stimulation (TMS)³ given that these modalities are relatively safe, noninvasive, and can be performed simultaneously with neurocognitive interventions. We review the concept of "state dependent" effects of NIBS and highlight how simultaneous or sequential cognitive interventions could help optimize NIBS therapy by providing further control of ongoing neural activity in targeted neural networks. This review spans a range of neuropsychiatric disorders including major depressive disorder, schizophrenia, generalized anxiety, and autism. For each disorder, we emphasize neuroanatomical circuitry that could be engaged with combination therapy and critically discuss the literature that has begun to emerge. Finally, we present possible underlying mechanisms and propose future research strategies that may further refine the potential of combination therapies.

Corticospinal correlates of fast and slow adaptive processes in motor learning

Recent computational theories and behavioral observations suggest that motor learning is supported by multiple adaptation processes, operating on different timescales, but direct neural evidence is lacking. We tested this hypothesis by applying transcranial magnetic stimulation over motor cortex in 16 human subjects during a validated reach adaptation task. Motor-evoked potentials (MEPs) and cortical silent periods (CSPs) were recorded from the biceps brachii to assess modulations of corticospinal excitability as indices for corticospinal plasticity. Guided by a two-state adaptation model, we show that the MEP reflects an adaptive process that learns quickly but has poor retention, while the CSP correlates with a process that responds more slowly but retains information well. These results provide a physiological link between models of motor learning and distinct changes in corticospinal excitability. Our findings support the relationship between corticospinal gain modulations and the adaptive processes in motor learning. NEW & NOTEWORTHY Computational theories and behavioral observations suggest that motor learning is supported by multiple adaptation processes, but direct neural evidence is lacking. We tested this hypothesis by applying transcranial magnetic stimulation over human motor cortex during a reach adaptation task. Guided by a two-state adaptation model, we show that the motor-evoked potential reflects a process that adapts and decays quickly, whereas the cortical silent period reflects slow adaptation and decay.