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Romero JP, Martínez-Benito A, de Noreña D, Hurtado-Martínez A, Sánchez-Cuesta FJ, González-Zamorano Y, Moreno-Verdú M. Combined non-invasive neuromodulation using transcranial direct current stimulation, motor imagery and action observation for motor, cognitive and functional recovery in cortico-basal degeneration: a single case study. EXCLI JOURNAL 2024; 23:714-726. [PMID: 38887394 PMCID: PMC11180953 DOI: 10.17179/excli2024-7027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/24/2024] [Indexed: 06/20/2024]
Abstract
This case report presents a comprehensive assessment and therapeutic intervention using non-invasive motor cortex neuromodulation for a 70-year-old female patient diagnosed with corticobasal degeneration (CBD). The study followed the CARE guidelines. The patient meets the criteria for probable CBD, with neuroimaging evidence of exclusively cortical impairment. The patient underwent a non-invasive neuromodulation protocol involving transcranial direct current stimulation (tDCS) and action observation plus motor imagery (AO+MI). The neuromodulation protocol comprised 20 sessions involving tDCS over the primary motor cortex and combined AO+MI. Anodal tDCS was delivered a 2 mA excitatory current for 20 minutes. AO+MI focused on lower limb movements, progressing over four weeks with video observation and gradual execution, both weekly and monthly. The neuromodulation techniques were delivered online (i.e. applied simultaneously in each session). Outcome measures were obtained at baseline, post-intervention and follow-up (1 month later), and included motor (lower limb), cognitive/neuropsychological and functional assessments. Walking speed improvements were not observed, but balance (Berg Balance Scale) and functional strength (Five Times Sit-to-Stand Test) improved post-treatment. Long-term enhancements in attentional set-shifting, inhibitory control, verbal attentional span, and working memory were found. There was neurophysiological evidence of diminished intracortical inhibition. Functional changes included worsening in Cortico Basal Ganglia Functional Scale score. Emotional well-being and general health (SF-36) increased immediately after treatment but were not sustained, while Falls Efficacy Scale International showed only long-term improvement. The findings suggest potential benefits of the presented neuromodulation protocol for CBD patients, highlighting multifaceted outcomes in motor, cognitive, and functional domains.
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Affiliation(s)
- Juan Pablo Romero
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Francisco de Vitoria University, Pozuelo de Alarcón, 28223, Spain
- Facultad de Ciencias Experimentales, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223, Spain
- Brain Damage Unit, Beata María Ana Hospital, Madrid, 28007, Spain
- Cognitive Neuroscience, Pain and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
| | - Alexis Martínez-Benito
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Francisco de Vitoria University, Pozuelo de Alarcón, 28223, Spain
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
| | - David de Noreña
- Brain Damage Unit, Beata María Ana Hospital, Madrid, 28007, Spain
| | - Alfonso Hurtado-Martínez
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Francisco de Vitoria University, Pozuelo de Alarcón, 28223, Spain
- Facultad de Ciencias Experimentales, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223, Spain
| | - Francisco José Sánchez-Cuesta
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Francisco de Vitoria University, Pozuelo de Alarcón, 28223, Spain
- Facultad de Ciencias Experimentales, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223, Spain
| | - Yeray González-Zamorano
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Francisco de Vitoria University, Pozuelo de Alarcón, 28223, Spain
- Cognitive Neuroscience, Pain and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
- Escuela Internacional de Doctorado, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28933 Alcorcón, Spain
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28933 Alcorcón, Spain
| | - Marcos Moreno-Verdú
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Francisco de Vitoria University, Pozuelo de Alarcón, 28223, Spain
- Brain, Action and Skill Laboratory (BAS-Lab), Institute of Neuroscience (Cognition and Systems Division), UC Louvain, 1200 Woluwe-Saint-Laimbert, Belgium
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2
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Kang K, Stenum J, Roemmich RT, Heller NH, Jouny C, Pantelyat A. Neurologic music therapy combined with EEG-tDCS for upper motor extremity performance in patients with corticobasal syndrome: Study protocol for a novel approach. Contemp Clin Trials 2023; 125:107058. [PMID: 36549380 DOI: 10.1016/j.cct.2022.107058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Corticobasal syndrome (CBS) is an atypical parkinsonian disorder that involves degeneration of brain regions associated with motor coordination and sensory processing. Combining transcranial direct current stimulation (tDCS) with rehabilitation training has been shown to improve upper-limb performance in other disease models. Here, we describe the protocol investigating whether tDCS with neurologic music therapy (NMT) (patterned sensory enhancement and therapeutic instrumental music performance) enhances functional arm/hand performance in individuals with CBS. METHODS Study participants are randomly assigned to six 30-min sessions (twice per week for 3 weeks) of NMT + either sham tDCS or active tDCS. We aim to stimulate the frontoparietal cortex, which is associated with movement execution/coordination and sensory processing. The hemisphere contralateral to the more affected arm is stimulated (total stimulation current of 2 mA from 5 dime-sized electrodes). Individualized NMT sessions designed to exercise the upper limb are provided. Participants undergo gross/fine motor, cognitive and emotional assessments at baseline and follow-up (one month after the final session). To investigate the immediate effects of tDCS and NMT training, gross /fine motor, affective level, and kinematic parameter measurements using motion sensors are collected before and after each session. Electroencephalography is used to collect electrical neurophysiological responses before, during, and after tDCS+NMT sessions. The study participants, neurologic music therapist and outcome assessor are blinded to whether participants are in the sham or active tDCS group. CONCLUSION This noninvasive and patient-centered clinical trial for CBS may provide insight into rehabilitation options that are sorely lacking in this population.
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Affiliation(s)
- Kyurim Kang
- School of Medicine, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America; Center for Music and Medicine, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America
| | - Jan Stenum
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, MD, United States of America; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Ryan T Roemmich
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, MD, United States of America; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nathan H Heller
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, United States of America
| | - Christophe Jouny
- School of Medicine, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America
| | - Alexander Pantelyat
- School of Medicine, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America; Center for Music and Medicine, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America.
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Toprak G, Hanoglu L, Cakir T, Guntekin B, Velioglu HA, Yulug B. DLPF Targeted Repetitive Transcranial Magnetic Stimulation Improves Brain Glucose Metabolism Along with the Clinical and Electrophysiological Parameters in CBD Patients. Endocr Metab Immune Disord Drug Targets 2022; 22:415-424. [PMID: 35100961 DOI: 10.2174/1871530322666220131120349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/24/2021] [Accepted: 07/14/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Corticobasal Degeneration (CBD) is a rare neurological disease caused by the pathological accumulation of tau protein. The primary pathological features of CBD include progressive neurodegenerative processes resulting in remarkable frontoparietal and basal ganglia atrophy. OBJECTIVE Like in many other neurodegenerative disorders, there is still no effective disease-modifying drug therapy in CBD. Therefore, the development of new treatment methods is of great importance. In this study, we aimed to assess the stimulating effects of high-frequency DLPFC rTMS on the motor, cognitive and behavioral disturbances in four CBD patients. METHODS Four (three females, one male) CBD patients who had been diagnosed as CBD were enrolled in this study. Patients were evaluated before and after the rTMS procedure regarding the motor, neuropsychometric and behavioral tests. The results of statistical analysis of behavioral and neuropsychometric evaluation were assessed via SPSS 18.0 package program. Data are expressed as mean, standard deviation. Before and after values of the groups were compared with the Wilcoxon sign rank test, and p<0.05 was considered significant. RESULTS We have provided strong preliminary evidence that the improvement in clinical parameters was associated with the normalizations of the theta activity and glucose metabolism. CONCLUSION Our current results are consistent with some previous trials showing a strong association between DLPFC targeted rTMS and electrophysiological normalizations in the left DLPFC.
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Affiliation(s)
- Guven Toprak
- Department of Clinical Electrophysiology, Neuroimaging and Neuromodulation, Istanbul Medipol University, Istanbul, Turkey
| | - Lutfu Hanoglu
- Department of Neurology, Istanbul Medipol University School of Medicine, Istanbul, Turkey
| | - Tansel Cakir
- Department of Nuclear Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Bahar Guntekin
- Department of Clinical Electrophysiology, Neuroimaging and Neuromodulation, Istanbul Medipol University, Istanbul, Turkey
| | - Halil Aziz Velioglu
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Health Sciences and Technology Research Institute (SABITA), Regenerative and Restorative Medicine Research Center (REMER), Functional Imaging and Cognitive-Affective Neuroscience Lab (fINCAN), Istanbul Medipol University, Istanbul, Turkey
| | - Burak Yulug
- Department of Neurology, Alanya Alaaddin Keykubat University School of Medicine, Alanya/Antalya, Turkey
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Ferrazzoli D, Ortelli P, Volpe D, Cucca A, Versace V, Nardone R, Saltuari L, Sebastianelli L. The Ties That Bind: Aberrant Plasticity and Networks Dysfunction in Movement Disorders-Implications for Rehabilitation. Brain Connect 2021; 11:278-296. [PMID: 33403893 DOI: 10.1089/brain.2020.0971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Movement disorders encompass various conditions affecting the nervous system. The pathological processes underlying movement disorders lead to aberrant synaptic plastic changes, which in turn alter the functioning of large-scale brain networks. Therefore, clinical phenomenology does not only entail motor symptoms but also cognitive and motivational disturbances. The result is the disruption of motor learning and motor behavior. Due to this complexity, the responsiveness to standard therapies could be disappointing. Specific forms of rehabilitation entailing goal-based practice, aerobic training, and the use of noninvasive brain stimulation techniques could "restore" neuroplasticity at motor-cognitive circuitries, leading to clinical gains. This is probably associated with modulations occurring at both molecular (synaptic) and circuitry levels (networks). Several gaps remain in our understanding of the relationships among plasticity and neural networks and how neurorehabilitation could promote clinical gains is still unclear. Purposes: In this review, we outline first the networks involved in motor learning and behavior and analyze which mechanisms link the pathological synaptic plastic changes with these networks' disruption in movement disorders. Therefore, we provide theoretical and practical bases to be applied for treatment in rehabilitation.
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Affiliation(s)
- Davide Ferrazzoli
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno-Sterzing, Italy
| | - Paola Ortelli
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno-Sterzing, Italy
| | - Daniele Volpe
- Fresco Parkinson Center, Villa Margherita, S. Stefano Riabilitazione, Vicenza, Italy
| | - Alberto Cucca
- Fresco Parkinson Center, Villa Margherita, S. Stefano Riabilitazione, Vicenza, Italy.,Department of Neurology, The Marlene & Paolo Fresco Institute for Parkinson's & Movement Disorders, NYU School of Medicine, New York, New York, USA.,Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno-Sterzing, Italy
| | - Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital (SABES-ASDAA), Merano-Meran, Italy.,Department of Neurology, Christian Doppler Medical Center, Paracelsus University Salzburg, Salzburg, Austria
| | - Leopold Saltuari
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno-Sterzing, Italy
| | - Luca Sebastianelli
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno-Sterzing, Italy
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Sanches C, Stengel C, Godard J, Mertz J, Teichmann M, Migliaccio R, Valero-Cabré A. Past, Present, and Future of Non-invasive Brain Stimulation Approaches to Treat Cognitive Impairment in Neurodegenerative Diseases: Time for a Comprehensive Critical Review. Front Aging Neurosci 2021; 12:578339. [PMID: 33551785 PMCID: PMC7854576 DOI: 10.3389/fnagi.2020.578339] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/07/2020] [Indexed: 12/14/2022] Open
Abstract
Low birth rates and increasing life expectancy experienced by developed societies have placed an unprecedented pressure on governments and the health system to deal effectively with the human, social and financial burden associated to aging-related diseases. At present, ∼24 million people worldwide suffer from cognitive neurodegenerative diseases, a prevalence that doubles every five years. Pharmacological therapies and cognitive training/rehabilitation have generated temporary hope and, occasionally, proof of mild relief. Nonetheless, these approaches are yet to demonstrate a meaningful therapeutic impact and changes in prognosis. We here review evidence gathered for nearly a decade on non-invasive brain stimulation (NIBS), a less known therapeutic strategy aiming to limit cognitive decline associated with neurodegenerative conditions. Transcranial Magnetic Stimulation and Transcranial Direct Current Stimulation, two of the most popular NIBS technologies, use electrical fields generated non-invasively in the brain to long-lastingly enhance the excitability/activity of key brain regions contributing to relevant cognitive processes. The current comprehensive critical review presents proof-of-concept evidence and meaningful cognitive outcomes of NIBS in eight of the most prevalent neurodegenerative pathologies affecting cognition: Alzheimer's Disease, Parkinson's Disease, Dementia with Lewy Bodies, Primary Progressive Aphasias (PPA), behavioral variant of Frontotemporal Dementia, Corticobasal Syndrome, Progressive Supranuclear Palsy, and Posterior Cortical Atrophy. We analyzed a total of 70 internationally published studies: 33 focusing on Alzheimer's disease, 19 on PPA and 18 on the remaining neurodegenerative pathologies. The therapeutic benefit and clinical significance of NIBS remains inconclusive, in particular given the lack of a sufficient number of double-blind placebo-controlled randomized clinical trials using multiday stimulation regimes, the heterogeneity of the protocols, and adequate behavioral and neuroimaging response biomarkers, able to show lasting effects and an impact on prognosis. The field remains promising but, to make further progress, research efforts need to take in account the latest evidence of the anatomical and neurophysiological features underlying cognitive deficits in these patient populations. Moreover, as the development of in vivo biomarkers are ongoing, allowing for an early diagnosis of these neuro-cognitive conditions, one could consider a scenario in which NIBS treatment will be personalized and made part of a cognitive rehabilitation program, or useful as a potential adjunct to drug therapies since the earliest stages of suh diseases. Research should also integrate novel knowledge on the mechanisms and constraints guiding the impact of electrical and magnetic fields on cerebral tissues and brain activity, and incorporate the principles of information-based neurostimulation.
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Affiliation(s)
- Clara Sanches
- Cerebral Dynamics, Plasticity and Rehabilitation Group, FRONTLAB Team, CNRS UMR 7225, INSERM U 1127, Institut du Cerveau, Sorbonne Universités, Paris, France
| | - Chloé Stengel
- Cerebral Dynamics, Plasticity and Rehabilitation Group, FRONTLAB Team, CNRS UMR 7225, INSERM U 1127, Institut du Cerveau, Sorbonne Universités, Paris, France
| | - Juliette Godard
- Cerebral Dynamics, Plasticity and Rehabilitation Group, FRONTLAB Team, CNRS UMR 7225, INSERM U 1127, Institut du Cerveau, Sorbonne Universités, Paris, France
| | - Justine Mertz
- Cerebral Dynamics, Plasticity and Rehabilitation Group, FRONTLAB Team, CNRS UMR 7225, INSERM U 1127, Institut du Cerveau, Sorbonne Universités, Paris, France
| | - Marc Teichmann
- Cerebral Dynamics, Plasticity and Rehabilitation Group, FRONTLAB Team, CNRS UMR 7225, INSERM U 1127, Institut du Cerveau, Sorbonne Universités, Paris, France.,National Reference Center for Rare or Early Onset Dementias, Department of Neurology, Institute of Memory and Alzheimer's Disease, Pitié-Salpêtrière Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
| | - Raffaella Migliaccio
- Cerebral Dynamics, Plasticity and Rehabilitation Group, FRONTLAB Team, CNRS UMR 7225, INSERM U 1127, Institut du Cerveau, Sorbonne Universités, Paris, France.,National Reference Center for Rare or Early Onset Dementias, Department of Neurology, Institute of Memory and Alzheimer's Disease, Pitié-Salpêtrière Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
| | - Antoni Valero-Cabré
- Cerebral Dynamics, Plasticity and Rehabilitation Group, FRONTLAB Team, CNRS UMR 7225, INSERM U 1127, Institut du Cerveau, Sorbonne Universités, Paris, France.,Laboratory for Cerebral Dynamics Plasticity & Rehabilitation, Boston University School of Medicine, Boston, MA, United States.,Cognitive Neuroscience and Information Technology Research Program, Open University of Catalonia, Barcelona, Spain
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6
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Ganguly J, Murgai A, Sharma S, Aur D, Jog M. Non-invasive Transcranial Electrical Stimulation in Movement Disorders. Front Neurosci 2020; 14:522. [PMID: 32581682 PMCID: PMC7290124 DOI: 10.3389/fnins.2020.00522] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/27/2020] [Indexed: 12/19/2022] Open
Abstract
Dysfunction within large-scale brain networks as the basis for movement disorders is an accepted hypothesis. The treatment options for restoring network function are limited. Non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation are now being studied to modify the network. Transcranial electrical stimulation (tES) is also a portable, cost-effective, and non-invasive way of network modulation. Transcranial direct current stimulation and transcranial alternating current stimulation have been studied in Parkinson’s disease, dystonia, tremor, and ataxia. Transcranial pulsed current stimulation and transcranial random noise stimulation are not yet studied enough. The literature in the use of these techniques is intriguing, yet many unanswered questions remain. In this review, we highlight the studies using these four potential tES techniques and their electrophysiological basis and consider the therapeutic implication in the field of movement disorders. The objectives are to consolidate the current literature, demonstrate that these methods are feasible, and encourage the application of such techniques in the near future.
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Affiliation(s)
- Jacky Ganguly
- Movement Disorder Centre, London Health Sciences Centre, The University of Western Ontario, London, ON, Canada
| | - Aditya Murgai
- Movement Disorder Centre, London Health Sciences Centre, The University of Western Ontario, London, ON, Canada
| | - Soumya Sharma
- Movement Disorder Centre, London Health Sciences Centre, The University of Western Ontario, London, ON, Canada
| | - Dorian Aur
- Movement Disorder Centre, London Health Sciences Centre, The University of Western Ontario, London, ON, Canada
| | - Mandar Jog
- Movement Disorder Centre, London Health Sciences Centre, The University of Western Ontario, London, ON, Canada
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7
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Madden DL, Sale MV, O'Sullivan J, Robinson GA. Improved language production with transcranial direct current stimulation in progressive supranuclear palsy. Neuropsychologia 2019; 127:148-157. [PMID: 30836131 DOI: 10.1016/j.neuropsychologia.2019.02.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 12/19/2018] [Accepted: 02/28/2019] [Indexed: 01/05/2023]
Abstract
Progressive supranuclear palsy (PSP) is an atypical parkinsonian disorder that can present with language production deficits in addition to the characteristic progressive parkinsonian motor symptoms. Although typical parkinsonism treatments such as pharmacotherapy are not effective in PSP, non-invasive brain stimulation techniques such as transcranial direct current stimulation (tDCS) have shown promise for treating cognitive deficits relating to this disorder. We report the case of KN, who presented with reduced verbal fluency and connected speech production in the context of PSP. KN completed a set of language tasks, followed by an alternate version of the tasks in conjunction with either sham or active tDCS over the left dorsolateral prefrontal cortex (DLPFC) across four sessions. Results showed improved performance with active stimulation compared to sham stimulation for phonemic fluency and action naming, as well as mixed results suggesting possible benefits for connected speech production. There were no benefits of active stimulation for control tasks, indicating that tDCS can produce specific benefits for phonemic fluency, action naming, and connected speech production in PSP. These promising, preliminary findings warrant further investigation into whether these benefits of tDCS can be a useful therapeutic tool for PSP patients to maintain language.
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Affiliation(s)
- Daniel L Madden
- Neuropsychology Research Unit, School of Psychology, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia
| | - Martin V Sale
- School of Health and Rehabilitation Sciences, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia; Queensland Brain Institute, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia
| | - John O'Sullivan
- Neurology Department, Royal Brisbane and Women's Hospital, Herston, Brisbane, Australia; Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Brisbane, Australia
| | - Gail A Robinson
- Neuropsychology Research Unit, School of Psychology, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia; Queensland Brain Institute, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia; Neurology Department, Royal Brisbane and Women's Hospital, Herston, Brisbane, Australia.
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8
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Pini L, Manenti R, Cotelli M, Pizzini FB, Frisoni GB, Pievani M. Non-Invasive Brain Stimulation in Dementia: A Complex Network Story. NEURODEGENER DIS 2019; 18:281-301. [PMID: 30695786 DOI: 10.1159/000495945] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/30/2018] [Indexed: 11/19/2022] Open
Abstract
Non-invasive brain stimulation (NIBS) is emerging as a promising rehabilitation tool for a number of neurodegenerative diseases. However, the therapeutic mechanisms of NIBS are not completely understood. In this review, we will summarize NIBS results in the context of brain imaging studies of functional connectivity and metabolites to gain insight into the possible mechanisms underlying recovery. We will briefly discuss how the clinical manifestations of common neurodegenerative disorders may be related with aberrant connectivity within large-scale neural networks. We will then focus on recent studies combining resting-state functional magnetic resonance imaging with NIBS to delineate how stimulation of different brain regions induce complex network modifications, both at the local and distal level. Moreover, we will review studies combining magnetic resonance spectroscopy and NIBS to investigate how microscale changes are related to modifications of large-scale networks. Finally, we will re-examine previous NIBS studies in dementia in light of this network perspective. A better understanding of NIBS impact on the functionality of large-scale brain networks may be useful to design beneficial treatments for neurodegenerative disorders.
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Affiliation(s)
- Lorenzo Pini
- Laboratory Alzheimer's Neuroimaging & Epidemiology, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Rosa Manenti
- Neuropsychology Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Maria Cotelli
- Neuropsychology Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Francesca B Pizzini
- Neuroradiology, Department of Diagnostics and Pathology, Verona University Hospital, Verona, Italy
| | - Giovanni B Frisoni
- Laboratory Alzheimer's Neuroimaging & Epidemiology, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy.,University Hospitals and University of Geneva, Geneva, Switzerland
| | - Michela Pievani
- Laboratory Alzheimer's Neuroimaging & Epidemiology, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy,
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9
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Ferrucci R, Mrakic-Sposta S, Gardini S, Ruggiero F, Vergari M, Mameli F, Arighi A, Spallazzi M, Barocco F, Michelini G, Pietroboni AM, Ghezzi L, Fumagalli GG, D'Urso G, Caffarra P, Scarpini E, Priori A, Marceglia S. Behavioral and Neurophysiological Effects of Transcranial Direct Current Stimulation (tDCS) in Fronto-Temporal Dementia. Front Behav Neurosci 2018; 12:235. [PMID: 30420799 PMCID: PMC6215856 DOI: 10.3389/fnbeh.2018.00235] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 09/20/2018] [Indexed: 11/13/2022] Open
Abstract
Fronto-temporal dementia (FTD) is the clinical-diagnostic term that is now preferred to describe patients with a range of progressive dementia syndromes associated with focal atrophy of the frontal and anterior temporal cerebral regions. Currently available FTD medications have been used to control behavioral symptoms, even though they are ineffective in some patients, expensive and may induce adverse effects. Alternative therapeutic approaches are worth pursuing, such as non-invasive brain stimulation with transcranial direct current (tDCS). tDCS has been demonstrated to influence neuronal excitability and reported to enhance cognitive performance in dementia. The aim of this study was to investigate whether applying Anodal tDCS (2 mA intensity, 20 min) over the fronto-temporal cortex bilaterally in five consecutive daily sessions would improve cognitive performance and behavior symptoms in FTD patients, also considering the neuromodulatory effect of stimulation on cortical electrical activity measured through EEG. We recruited 13 patients with FTD and we tested the effect of Anodal and Sham (i.e., placebo) tDCS in two separate experimental sessions. In each session, at baseline (T0), after 5 consecutive days (T1), after 1 week (T2), and after 4 weeks (T3) from the end of the treatment, cognitive and behavioral functions were tested. EEG (21 electrodes, 10-20 international system) was recorded for 5 min with eyes closed at the same time points in nine patients. The present findings showed that Anodal tDCS applied bilaterally over the fronto-temporal cortex significantly improves (1) neuropsychiatric symptoms (as measured by the neuropsychiatric inventory, NPI) in FTD patients immediately after tDCS treatment, and (2) simple visual reaction times (sVRTs) up to 1 month after tDCS treatment. These cognitive improvements significantly correlate with the time course of the slow EEG oscillations (delta and theta bands) measured at the same time points. Even though further studies on larger samples are needed, these findings support the effectiveness of Anodal tDCS over the fronto-temporal regions in FTD on attentional processes that might be correlated to a normalized EEG low-frequency pattern.
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Affiliation(s)
- Roberta Ferrucci
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
- “Aldo Ravelli” Research Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan Medical School, Milan, Italy
- III Neurological Clinic, San Paolo Hospital, Milan, Italy
| | - Simona Mrakic-Sposta
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
- National Council of Research, Institute of Bioimaging and Molecular Physiology, Segrate, Italy
| | - Simona Gardini
- Department of Neuroscience, University of Parma, Parma, Italy
| | - Fabiana Ruggiero
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vergari
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Mameli
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Arighi
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, “Dino Ferrari” center, University of Milan, Milan, Italy
| | - Marco Spallazzi
- Dementia Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Federica Barocco
- Dementia Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | | | - Anna Margherita Pietroboni
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, “Dino Ferrari” center, University of Milan, Milan, Italy
| | - Laura Ghezzi
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, “Dino Ferrari” center, University of Milan, Milan, Italy
| | - Giorgio Giulio Fumagalli
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, “Dino Ferrari” center, University of Milan, Milan, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | | | - Paolo Caffarra
- Dementia Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
- Center for Cognitive Disorders and Dementia, AUSL of Parma, Parma, Italy
| | - Elio Scarpini
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, “Dino Ferrari” center, University of Milan, Milan, Italy
| | - Alberto Priori
- “Aldo Ravelli” Research Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan Medical School, Milan, Italy
- III Neurological Clinic, San Paolo Hospital, Milan, Italy
| | - Sara Marceglia
- Fondazione Ca' Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
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10
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Electrical brain stimulation in different variants of primary progressive aphasia: A randomized clinical trial. ALZHEIMERS & DEMENTIA-TRANSLATIONAL RESEARCH & CLINICAL INTERVENTIONS 2018; 4:461-472. [PMID: 30258975 PMCID: PMC6153381 DOI: 10.1016/j.trci.2018.08.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction Transcranial direct current stimulation (tDCS) has been recently shown to improve language outcomes in primary progressive aphasia (PPA) but most studies are small and the influence of PPA variant is unknown. Methods Thirty-six patients with PPA participated in a randomized, sham-controlled, double-blind, within-subject crossover design for 15 daily sessions of stimulation coupled with written naming/spelling therapy. Outcome measures were letter accuracy of treated and untreated words immediately after and at 2 weeks and 2 months posttreatment. Results tDCS treatment was more effective than sham: gains for treated words were maintained 2 months posttreatment; gains from tDCS also generalized to untreated words and were sustained 2 months posttreatment. Different effects were obtained for each PPA variant, with no tDCS advantage for semantic variant PPA. Discussion The study supports using tDCS as an adjunct to written language interventions in individuals with logopenic or nonfluent/agrammatic PPA seeking compensatory treatments in clinical settings.
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11
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Pisoni A, Mattavelli G, Casarotti A, Comi A, Riva M, Bello L, Papagno C. Object-action dissociation: A voxel-based lesion-symptom mapping study on 102 patients after glioma removal. NEUROIMAGE-CLINICAL 2018; 18:986-995. [PMID: 29876283 PMCID: PMC5988029 DOI: 10.1016/j.nicl.2018.03.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 03/06/2018] [Accepted: 03/20/2018] [Indexed: 11/25/2022]
Abstract
Data concerning the neural basis of noun and verb processing are inconsistent. Some authors assume that action-verb processing is based on frontal areas while nouns processing relies on temporal regions; others argue that the circuits processing verbs and nouns are closely interconnected in a predominantly left-lateralized fronto-temporal-parietal network; yet, other researchers consider that the primary motor cortex plays a crucial role in processing action verbs. In the present study, one hundred and two patients with a tumour either in the right or left hemisphere were submitted to picture naming of objects and actions before and after surgery. To test the effect of specific brain regions in object and action naming, patients' lesions were mapped and voxel-lesion-symptom mapping (VLSM) was computed. Behavioural results showed that left-brain damaged patients were significantly more impaired than right brain-damaged patients. The VLSM showed that these two grammatical classes are segregated in the left hemisphere. In particular, scores in naming of objects correlated with damage to the anterior temporal region, while scores in naming of actions correlated with lesions in the parietal areas and in the posterior temporal cortex. In addition, VLSM analyses carried out on non-linguistic tasks were not significant, confirming that the regions associated with deficits in object and action naming were not generally engaged in all cognitive tasks. Finally, the involvement of subcortical pathways was investigated and the inferior longitudinal fasciculus proved to play a role in object naming, while no specific bundle was identified for actions.
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Affiliation(s)
- Alberto Pisoni
- Dipartimento di Psicologia, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Milano 20126, Italy; NeuroMi (Neuroscience Center), University of Milano-Bicocca, Italy
| | - Giulia Mattavelli
- Dipartimento di Psicologia, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Milano 20126, Italy; NeuroMi (Neuroscience Center), University of Milano-Bicocca, Italy
| | - Alessandra Casarotti
- Unit of Oncological Neurosurgery, Humanitas Research Hospital, via Manzoni 56, Italy
| | - Alessandro Comi
- Dipartimento di Psicologia, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Milano 20126, Italy
| | - Marco Riva
- Unit of Oncological Neurosurgery, Humanitas Research Hospital, via Manzoni 56, Italy
| | - Lorenzo Bello
- Unit of Oncological Neurosurgery, Humanitas Research Hospital, via Manzoni 56, Italy; Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, via Festa del Perdono 7, Milano 20122, Italy
| | - Costanza Papagno
- Dipartimento di Psicologia, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Milano 20126, Italy; CIMeC, CeRiN, via Matteo del Ben 5/b, University of Trento and Rovereto, Rovereto 38068, Italy.
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12
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Zheng X, Dai W, Alsop DC, Schlaug G. Modulating transcallosal and intra-hemispheric brain connectivity with tDCS: Implications for interventions in Aphasia. Restor Neurol Neurosci 2018; 34:519-30. [PMID: 27472845 DOI: 10.3233/rnn-150625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/OBJECTIVE Transcranial direct current stimulation (tDCS) can enhance or diminish cortical excitability levels depending on the polarity of the stimulation. One application of non-invasive brain-stimulation has been to modulate a possible inter-hemispheric disinhibition after a stroke. This disinhibition model has been developed mainly for the upper extremity motor system, but it is not known whether the language/speech-motor system shows a similar inter-hemispheric interaction. We aimed to examine physiological evidence of inter- and intra-hemispheric connectivity changes induced by tDCS of the right inferior frontal gyrus (IFG) using arterial-spin labeling (ASL) MRI. METHODS Using an MR-compatible DC-Stimulator, we applied anodal stimulation to the right IFG region of nine healthy adults while undergoing non-invasive cerebral blood flow imaging with arterial-spin labeling (ASL) before, during, and after the stimulation. All ASL images were then normalized and timecourses were extracted in regions of interest (ROIs), which were the left and right IFG regions, and the right supramarginal gyrus (SMG) in the inferior parietal lobule. Two additional ROIs (the right occipital lobe and the left fronto-orbital region) were taken as control regions. RESULTS Using regional correlation coefficients as a surrogate marker of connectivity, we could show that inter-hemispheric connectivity (right IFG with left IFG) decreased significantly (p < 0.05; r-scores from 0.67 to 0.53) between baseline and post-stimulation, while the intra-hemispheric connectivity (right IFG with right SMG) increased significantly (p < 0.05;r-scores from 0.74 to 0.81). A 2 × 2 ANOVA found a significant main effect of HEMISPHERE (F(8) = 6.83, p < 0.01) and a significant HEMISPHERE-by-TIME interaction (F(8) = 4.24, p < 0.05) in connectivity changes. The correlation scores did not change significantly in the control region pairs (right IFG with right occipital and right IFG with left fronto-orbital) over time. CONCLUSION Using an MR-compatible DC stimulator we showed that ASL-MRI can detect tDCS-induced modulation of brain connectivity within and between hemispheres. These findings might affect trial designs focusing on modulating the non-dominant hemisphere to enhance language/speech-motor functions.
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Affiliation(s)
- Xin Zheng
- Department of Neurology, Neuroimaging and Stroke Recovery Laboratory, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Weiying Dai
- Division of MR Research, Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - David C Alsop
- Division of MR Research, Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Gottfried Schlaug
- Department of Neurology, Neuroimaging and Stroke Recovery Laboratory, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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13
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Bikson M, Grossman P, Thomas C, Zannou AL, Jiang J, Adnan T, Mourdoukoutas AP, Kronberg G, Truong D, Boggio P, Brunoni AR, Charvet L, Fregni F, Fritsch B, Gillick B, Hamilton RH, Hampstead BM, Jankord R, Kirton A, Knotkova H, Liebetanz D, Liu A, Loo C, Nitsche MA, Reis J, Richardson JD, Rotenberg A, Turkeltaub PE, Woods AJ. Safety of Transcranial Direct Current Stimulation: Evidence Based Update 2016. Brain Stimul 2016; 9:641-661. [PMID: 27372845 PMCID: PMC5007190 DOI: 10.1016/j.brs.2016.06.004] [Citation(s) in RCA: 802] [Impact Index Per Article: 100.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/10/2016] [Accepted: 06/12/2016] [Indexed: 01/13/2023] Open
Abstract
This review updates and consolidates evidence on the safety of transcranial Direct Current Stimulation (tDCS). Safety is here operationally defined by, and limited to, the absence of evidence for a Serious Adverse Effect, the criteria for which are rigorously defined. This review adopts an evidence-based approach, based on an aggregation of experience from human trials, taking care not to confuse speculation on potential hazards or lack of data to refute such speculation with evidence for risk. Safety data from animal tests for tissue damage are reviewed with systematic consideration of translation to humans. Arbitrary safety considerations are avoided. Computational models are used to relate dose to brain exposure in humans and animals. We review relevant dose-response curves and dose metrics (e.g. current, duration, current density, charge, charge density) for meaningful safety standards. Special consideration is given to theoretically vulnerable populations including children and the elderly, subjects with mood disorders, epilepsy, stroke, implants, and home users. Evidence from relevant animal models indicates that brain injury by Direct Current Stimulation (DCS) occurs at predicted brain current densities (6.3-13 A/m(2)) that are over an order of magnitude above those produced by conventional tDCS. To date, the use of conventional tDCS protocols in human trials (≤40 min, ≤4 milliamperes, ≤7.2 Coulombs) has not produced any reports of a Serious Adverse Effect or irreversible injury across over 33,200 sessions and 1000 subjects with repeated sessions. This includes a wide variety of subjects, including persons from potentially vulnerable populations.
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Affiliation(s)
- Marom Bikson
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA.
| | - Pnina Grossman
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA
| | - Chris Thomas
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA
| | | | - Jimmy Jiang
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA
| | - Tatheer Adnan
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA
| | | | - Greg Kronberg
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA
| | - Dennis Truong
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA
| | - Paulo Boggio
- Cognitive Neuroscience Laboratory and Developmental Disorders Program, Center for Health and Biological Sciences, Mackenzie Presbyterian University, Sao Paulo, Brazil
| | - André R Brunoni
- Service of Interdisciplinary Neuromodulation, Department and Institute of Psychiatry, Laboratory of Neurosciences (LIM-27), University of São Paulo, São Paulo, Brazil
| | - Leigh Charvet
- NYU MS Comprehensive Care Center, Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Felipe Fregni
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Brita Fritsch
- Department of Neurology, University Medical Center, Freiburg, Germany; BrainLinks-BrainTools Cluster of Excellence, University of Freiburg, Germany
| | - Bernadette Gillick
- Department of Physical Medicine and Rehabilitation, University of Minnesota Medical School, Minneapolis, MN
| | - Roy H Hamilton
- Laboratory for Cognition and Neural Stimulation, University of Pennsylvania, Philadelphia, PA, USA; Center for Cognitive Neuroscience, University of Pennsylvania, Philadelphia, PA, USA; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M Hampstead
- Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Jankord
- Applied Neuroscience, 711th Human Performance Wing, Air Force Research Laboratory, WPAFB, OH, USA
| | - Adam Kirton
- Departments of Pediatrics and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, NY, USA; Department of Social and Family Medicine, Albert Einstein College of Medicine, The Bronx, NY, USA
| | - David Liebetanz
- Department of Clinical Neurophysiology, University Medical Center, Georg-August-University, Goettingen 37075, Germany
| | - Anli Liu
- NYU Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
| | - Colleen Loo
- Psychiatry, Black Dog Institute, Clinical Academic, St George Hospital, University of New South Wales, Sydney, Australia
| | - Michael A Nitsche
- Department of Clinical Neurophysiology, University Medical Center, Georg-August-University, Goettingen 37075, Germany; Leibniz Research Centre for Working Environment and Human Factors at the TU Dortmund, Dortmund, Germany; Department of Neurology, University Medical Hospital Bergmannsheil, Bochum, Germany
| | - Janine Reis
- Department of Neurology, University Medical Center, Freiburg, Germany; BrainLinks-BrainTools Cluster of Excellence, University of Freiburg, Germany
| | - Jessica D Richardson
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Communication Sciences & Disorders, The University of South Carolina, Columbia, SC, USA; Department of Speech and Hearing Sciences, The University of New Mexico, Albuquerque, NM, USA
| | - Alexander Rotenberg
- Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, USA; Pediatric Neuromodulation Program, Division of Epilepsy and Neurophysiology, Department of Neurology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA
| | - Peter E Turkeltaub
- Department of Neurology, Georgetown University, Washington, DC, USA; Research Division, MedStar National Rehabilitation Hospital, Washington, DC, USA
| | - Adam J Woods
- Center for Cognitive Aging and Memory, Institute on Aging, Department of Aging and Geriatric Research, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
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