A Meta-Analysis of the Effectiveness of Different Cortical Targets Used in Repetitive Transcranial Magnetic Stimulation (rTMS) for the Treatment of Obsessive-Compulsive Disorder (OCD)

Randomised and sham-controlled trials (RCTs) of repetitive transcranial magnetic stimulation (rTMS) in the treatment of obsessive-compulsive disorder (OCD) have yielded conflicting results, which may be due to the variability in rTMS parameters used. We performed an updated systematic review and meta-analysis on the effectiveness of rTMS for the treatment of OCD and aimed to determine whether certain rTMS parameters, such as cortical target, may be associated with higher treatment effectiveness. After conducting a systematic literature review for RCTs on rTMS for OCD through to 1 December 2016 using MEDLINE, PubMed, Web of Science, PsycINFO, Google, and Google Scholar, we performed a random-effects meta-analysis with the outcome measure as pre-post changes in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores. To determine whether rTMS parameters may have influenced treatment effectiveness, studies were further analysed according to cortical target, stimulation frequency, and length of follow-up. Data were obtained from 18 RCTs on rTMS in the treatment of OCD. Overall, rTMS yielded a modest effect in reducing Y-BOCS scores with Hedge's g of 0.79 (95% CI = 0.43-1.15, p < 0.001). Stimulation of the supplementary motor area yielded the greatest reductions in Y-BOCS scores relative to other cortical targets. Subgroup analyses suggested that low frequency rTMS was more effective than high frequency rTMS. The effectiveness of rTMS was also greater at 12 weeks follow-up than at four weeks follow-up. Our meta-analysis implies that low frequency rTMS applied over the supplementary motor area may offer the greatest effectiveness in the treatment of OCD. The therapeutic effects of rTMS also appear to persist post-treatment and may offer beneficial long-term effectiveness. With our findings, it is suggested that future large-scale studies focus on the supplementary motor area and include follow-up periods of 12 weeks or more.

The effects of direct brain stimulation in humans depend on frequency, amplitude, and white-matter proximity

BACKGROUND

Researchers have used direct electrical brain stimulation to treat a range of neurological and psychiatric disorders. However, for brain stimulation to be maximally effective, clinicians and researchers should optimize stimulation parameters according to desired outcomes.

OBJECTIVE

The goal of our large-scale study was to comprehensively evaluate the effects of stimulation at different parameters and locations on neuronal activity across the human brain.

METHODS

To examine how different kinds of stimulation affect human brain activity, we compared the changes in neuronal activity that resulted from stimulation at a range of frequencies, amplitudes, and locations with direct human brain recordings. We recorded human brain activity directly with electrodes that were implanted in widespread regions across 106 neurosurgical epilepsy patients while systematically stimulating across a range of parameters and locations.

RESULTS

Overall, stimulation most often had an inhibitory effect on neuronal activity, consistent with earlier work. When stimulation excited neuronal activity, it most often occurred from high-frequency stimulation. These effects were modulated by the location of the stimulating electrode, with stimulation sites near white matter more likely to cause excitation and sites near gray matter more likely to inhibit neuronal activity.

CONCLUSION

By characterizing how different stimulation parameters produced specific neuronal activity patterns on a large scale, our results provide an electrophysiological framework that clinicians and researchers may consider when designing stimulation protocols to cause precisely targeted changes in human brain activity.

Unilateral deep brain stimulation suppresses alpha and beta oscillations in sensorimotor cortices

Deep brain stimulation (DBS) is an established therapy to treat motor symptoms in movement disorders such as Parkinson's disease (PD). The mechanisms leading to the high therapeutic effectiveness of DBS are poorly understood so far, but modulation of oscillatory activity is likely to play an important role. Thus, investigating the effect of DBS on cortical oscillatory activity can help clarifying the neurophysiological mechanisms of DBS. Here, we aimed at scrutinizing changes of cortical oscillatory activity by DBS at different frequencies using magnetoencephalography (MEG). MEG data from 17 PD patients were acquired during DBS of the subthalamic nucleus (STN) the day after electrode implantation and before implanting the pulse generator. We stimulated the STN unilaterally at two different stimulation frequencies, 130 Hz and 340 Hz using an external stimulator. Data from six patients had to be discarded due to strong artefacts and two other datasets were excluded since these patients were not able to finalize the paradigm. After DBS artefact removal, power spectral density (PSD) values of MEG were calculated for each individual patient and averaged over the group. DBS at both 130 Hz and 340 Hz led to a widespread suppression of cortical alpha/beta band activity (8-22 Hz) specifically over bilateral sensorimotor cortices. No significant differences were observed between the two stimulation frequencies. Our finding of a widespread suppression of cortical alpha/beta band activity is particularly interesting as PD is associated with pathologically increased levels of beta band activity in the basal ganglia-thalamo-cortical circuit. Therefore, suppression of such oscillatory activity might be an essential effect of DBS for relieving motor symptoms in PD and can be achieved at different stimulation frequencies above 100 Hz.

Bradykinesia induced by frequency-specific pallidal stimulation in patients with cervical and segmental dystonia

INTRODUCTION

Pallidal deep brain stimulation (DBS) is an effective treatment for patients with primary dystonia leading to a substantial reduction of symptom severity. However, stimulation induced side effects such as bradykinesia have also been reported recently. The influence of stimulation parameters on such side effects have not yet been systemically assessed in these patients.

METHODS

Here we tested the effect of stimulation frequency and duration of stimulation period on hand motor function in 22 patients with primary cervical and segmental dystonia using an unimanual tapping task. Patients performed the task at 4 different stimulation frequencies (0 Hz = OFF stimulation, 20, 50 and ≥130 Hz = high frequency stimulation) after either an SHORT (5 min, N = 16) or a LONG (60 min, N = 6) stimulation period (i.e. changing of DBS-frequency). The change of overall mobility under HFS compared to the preoperative state was assessed with a 5-point Likert-scale. Tapping performance was analysed using a repeated measures ANOVA with the main factor 'FREQUENCY'. Tapping performance at HFS and changes in general mobility were correlated using Spearman's Rho.

RESULTS

We found a frequency specific modulation of hand motor function: HFS led to deterioration and 20 Hz stimulation to improvement of tapping rate. The effects were predominant in the 'LONG' group suggesting a significant contribution of stimulation duration.

CONCLUSIONS

This is important to consider during DBS-programming and evaluation of potential side effects. Furthermore, the impairment in hand motor function under HFS was mirrored by the patients' observation of a deterioration of general mobility.

Wide-pulse, high-frequency, low-intensity neuromuscular electrical stimulation has potential for targeted strengthening of an intrinsic foot muscle: a feasibility study

Background

Strengthening the intrinsic foot muscles is a poorly understood and largely overlooked area. In this study, we explore the feasibility of strengthening m. abductor hallucis (AH) with a specific paradigm of neuromuscular electrical stimulation; one which is low-intensity in nature and designed to interleave physiologically-relevant low frequency stimulation with high-frequencies to enhance effective current delivery to spinal motoneurones, and enable a proportion of force produced by the target muscle to be generated from a central origin. We use standard neurophysiological measurements to evaluate the acute (~ 30 min) peripheral and central adaptations in healthy individuals.

Methods

The AH in the dominant foot of nine healthy participants was stimulated with 24 × 15 s trains of square wave (1 ms), constant current (150% of motor threshold), alternating (20 Hz–100 Hz) neuromuscular electrical stimulation interspersed with 45 s rest. Prior to the intervention, peripheral variables were evoked from the AH compound muscle action potential (M_wave) and corresponding twitch force in response to supramaximal (130%) medial plantar nerve stimulation. Central variables were evoked from the motor evoked potential (MEP) in response to suprathreshold (150%) transcranial magnetic stimulation of the motor cortex corresponding to the AH pathway. Follow-up testing occurred immediately, and 30 min after the intervention. In addition, the force-time-integrals (FTI) from the 1st and 24th WPHF trains were analysed as an index of muscle fatigue. All variables except FTI (T-test) were entered for statistical analysis using a single factor repeated measures ANOVA with alpha set at 0.05.

Results

FTI was significantly lower at the end of the electrical intervention compared to that evoked by the first train (p < 0.01). Only significant peripheral nervous system adaptations were observed, consistent with the onset of low-frequency fatigue in the muscle. In most of these variables, the effects persisted for 30 min after the intervention.

Conclusions

An acute session of wide-pulse, high-frequency, low-intensity electrical stimulation delivered directly to abductor hallucis in healthy feet induces muscle fatigue via adaptations at the peripheral level of the neuromuscular system. Our findings would appear to represent the first step in muscle adaptation to training; therefore, there is potential for using WPHF for intrinsic foot muscle strengthening.

Electronic supplementary material

The online version of this article (10.1186/s13047-018-0258-1) contains supplementary material, which is available to authorized users.

Synchronous transitions of up and down states in a network model based on stimulations

The phenomenon of spontaneous periodic up and down transitions is considered to be a significant characteristic of slow oscillations. Our previous theoretical studies have shown that the single neuron and network model can both exhibit spontaneous up and down transitions. Another characteristic of up and down dynamics is the synchronicity. So in this paper, we focused on the synchronized characteristic of up and down transitions in the network based on stimulations. Spontaneous activities showed no synchronous transitions between neurons. However, the external stimulation, mainly the stimulation frequency and the number of neurons stimulated on were related to the synchronous transitions of up and down states. The simulation results suggested that simultaneous high frequency excitation or firing of neurons in the network was responsible for the generation of synchronous transitions of up and down states. Through the observation and analysis of the findings, we have tried to explain the reason for synchronous up and down transitions and to lay the foundation for further work on the role of these synchronized transitions in cortex activity.

Transitory force decrease following a sudden reduction in stimulation frequency in motor units of rat medial gastrocnemius

Effects of a sudden decrease in the stimulation frequency for motor unit force were studied in rat medial gastrocnemius. For 161 functionally isolated single motor units of three types (S, FR, FF), unfused tetanic contractions were evoked by three-phase trains of stimuli (low-high-low frequency). The course of the tetanus at the onset of the third phase of the force recording was analyzed in tetani with variable fusion degree. For 78 units within the third phase of tetanus, a transitory force decrease to a level lower than in the first phase (identical frequency), was observed. This phenomenon was more frequent for fast fatigue resistant (65.9%) than for fast fatigable and slow motor units (27.1% and 35.5%, respectively). Moreover, the force decrease was strongest for fast resistant motor units (up to 36.5%) and when contractions evoked at variable frequencies of stimulation were compared, the highest amplitudes of the studied force decrease were noted for middle-fused tetani (0.50-0.90). A new phenomenon of transitory force decrease in tetanic contractions of motor units with a decrease in stimulation frequency was found. Most probably, the phenomenon is dependent on disturbances in the force transmission by collagen surrounding active muscles fibers.

Initial force production before sag is enhanced by prior contraction followed by a 3-minute rest period in fast motor units of the rat medial gastrocnemius

Unfused tetanic contractions evoked in fast motor units exhibit extra-efficient force production at the onset of contraction, an effect called "boost". Boost is diminished in subsequent contractions if there is a short rest period between contractions, but can be re-established with a longer period of rest. We tested the hypothesis that contractile activity and rest could enhance boost-related metrics. Two sets of 3 unfused tetani were evoked 3 min apart in fast fatigable (FF) and fast fatigue-resistant (FR) motor units of the rat medial gastrocnemius. The greatest changes occurred in the first unfused tetanic contractions. Relative to the first contraction in the first set, the first contraction in the second set exhibited higher peak force during boost in a subset of motor units (76% of FF and 48% of FR). Enhanced force during boost was influenced by interaction of slowing of twitch contraction time (up to 20% and 25%, for FF and FR motor units, respectively), half-relaxation time (up to 37% and 49% for FF and FR motor units, respectively), and potentiation of the first twitch (up to 13% and 5% for FF and FR motor units, respectively). Examination of twitches evoked between sets suggested opportunity for greater enhancement of boost with shorter intervening rest periods. The phenomenon of enhanced boost following motor unit activity may interest sports scientists.

Selective modulation of neuronal firing by pulse stimulations with different frequencies in rat hippocampus

Background

Deep brain stimulation (DBS) has a good prospect for treating many brain diseases. Recent studies have shown that axonal activation induced by pulse stimulations may play an important role in DBS therapies through wide projections of axonal fibers. However, it is undetermined whether the downstream neurons are inhibited or excited by axonal stimulation. The present study addressed the question in rat hippocampus by in vivo experiments.

Methods

Pulse stimulations with different frequencies (10–400 Hz) were applied to the Schaffer collateral, the afferent fiber of hippocampal CA1 region in anaesthetized rats. Single-unit spikes of interneurons and pyramidal cells in the downstream region of stimulation were recorded and evaluated.

Results

Stimulations with a lower frequency (10 or 20 Hz) did not change the firing rates of interneurons but decreased the firing rates of pyramidal cells (the principal neurons) significantly. The phase-locked firing of interneurons during these stimulations might increase the efficacy of GABAergic inhibitions on the principal neurons. However, stimulations with a higher frequency (100–400 Hz) increased the firing rates of both types of the neurons significantly. In addition, the increases of interneurons’ firing were greater than the increases of pyramidal cells. Presumably, increase of direct excitation from afferent impulses together with failure of GABAergic inhibition might result in the increase of pyramidal cells’ firing by a higher stimulation frequency. Furthermore, silent periods appeared immediately following the cessation of stimulations, indicating a full control of the neuronal firing by the stimulation pulses during axonal stimulation. Furthermore longer silent periods were associated with higher stimulation frequencies.

Conclusions

Low-frequency (10–20 Hz) and high-frequency (100–400 Hz) stimulations of afferent axonal fibers exerted opposite effects on principal neurons in rat hippocampus CA1. These results provide new information for advancing deep brain stimulation to treat different brain disorders.

Biomechanical conditioning of the motor unit transitory force decrease following a reduction in stimulation rate

BACKGROUND

The biomechanical background of the transitory force decrease following a sudden reduction in the stimulation frequency under selected experimental conditions was studied on fast resistant motor units (MUs) of rat medial gastrocnemius in order to better understand the mechanisms of changes in force transmission.

METHODS

Firstly, MUs were stimulated with three-phase trains of stimuli (low-high-low frequency pattern) to identify patterns when the strongest force decrease (3-36.5%) following the middle high frequency stimulation was observed. Then, in the second part of experiments, the MUs which presented the largest force decrease in the last low-frequency phase were alternatively tested under one of five conditions to analyse the influence of biomechanical factors of the force decrease: (1) determine the influence of muscle stretch on amplitude of the force decrease, (2) determine the numbers of interpulse intervals necessary to evoke the studied phenomenon, (3) study the influence of coactivation of other MUs on the studied force decrease, (4) test the presence of the transitory force decrease at progressive changes in stimulation frequency, (5) and perform mathematical analysis of changes in twitch-shape responses to individual stimuli within a tetanus phase with the studied force decrease.

RESULTS

Results indicated that (1) the force decrease was highest when the muscle passive stretch was optimal for the MU twitch (100 mN); (2) the middle high-frequency burst of stimuli composed of at least several pulses was able to evoke the force decrease; (3) the force decrease was eliminated by a coactivation of 10% or more MUs in the examined muscle; (4) the transitory force decrease occured also at the progressive decrease in stimulation frequency; and (5) a mathematical decomposition of contractions with the transitory force decrease into twitch-shape responses to individual stimuli revealed that the force decrease in question results from the decrease of twitch forces and a shortening in contraction time whereas further force restitution is related to the prolongation of relaxation.

CONCLUSIONS

High sensitivity to biomechanical conditioning indicates that the transitory force decrease is dependent on disturbances in the force transmission predominantly by collagen surrounding active muscle fibres.

Soleus H-reflex amplitude modulation during walking remains physiological during transspinal stimulation in humans

The soleus H-reflex modulation pattern was investigated during stepping following transspinal stimulation over the thoracolumbar region at 15, 30, and 50 Hz with 10 kHz carry-over frequency above and below the paresthesia threshold. The soleus H-reflex was elicited by posterior tibial nerve stimulation with a single 1 ms pulse at an intensity that the M-wave amplitudes ranged from 0 to 15% of the maximal M-wave evoked 80 ms after the test stimulus, and the soleus H-reflex was half the size of the maximal H-reflex evoked on the ascending portion of the recruitment curve. During treadmill walking, the soleus H-reflex was elicited every 2 or 3 steps, and stimuli were randomly dispersed across the step cycle which was divided in 16 equal bins. For each subject and condition, the soleus M-wave and H-reflex were normalized to the maximal M-wave. The soleus background electromyographic (EMG) activity was estimated as the linear envelope for 50 ms duration starting at 100 ms before posterior tibial nerve stimulation for each bin. The gain was determined as the slope of the relationship between the soleus H-reflex and the soleus background EMG activity. The soleus H-reflex phase-dependent amplitude modulation remained unaltered during transspinal stimulation, regardless frequency, or intensity. Similarly, the H-reflex slope and intercept remained the same for all transspinal stimulation conditions tested. Locomotor EMG activity was increased in knee extensor muscles during transspinal stimulation at 30 and 50 Hz throughout the step cycle while no effects were observed in flexor muscles. These findings suggest that transspinal stimulation above and below the paresthesia threshold at 15, 30, and 50 Hz does not block or impair spinal integration of proprioceptive inputs and increases activity of thigh muscles that affect both hip and knee joint movement. Transspinal stimulation may serve as a neurorecovery strategy to augment standing or walking ability in upper motoneuron lesions.

Frequency-dependent effects of superimposed NMES on spinal excitability in upper and lower limb muscles

Superimposing neuromuscular electrical stimulation (NMES) on voluntary contractions has proven to be highly effective for improving muscle strength and performance. These improvements might involve specific adaptations occurring at cortical and spinal level. The effects of NMES on corticospinal activation seem to be frequency dependent and differ between upper and lower limb muscles. The aim of this study was to investigate acute responses in spinal excitability, as measured by H-reflex amplitude of flexor carpi radialis (FCR) and soleus (SOL) muscles, after NMES superimposed on voluntary contractions (NMES + ISO) at two different pulse frequencies (40 and 80 Hz). Conditions involved fifteen intermittent contractions at submaximal level. Before and after each condition, H-reflexes were elicited in FCR and SOL muscles. H-reflex amplitudes increased in FCR and SOL following both NMES + ISO at 40 and 80 Hz. The potentiation of the H-reflex was greater following the 40 Hz condition compared to 80 Hz, although no differences between muscles emerged. These findings indicated that superimposing NMES has an excitatory effect on spinal motoneurons in both upper and lower limb muscles with an overall greater response after low frequency NMES. Such facilitation could be associated to enhanced somatosensory stimuli conjunctly with higher supraspinal downward commands.

Centrally mediated responses to NMES are influenced by muscle group and stimulation parameters

Wide-pulse high-frequency neuromuscular electrical stimulation (WPHF NMES) can generate a progressive increase in tetanic force through reflexive recruitment of motor units, called extra force. This phenomenon has previously been observed on different muscle groups, but little is known on potential inter-muscle differences. We compared extra force and sustained electromyographic (EMG) activity induced by NMES between plantar flexors, knee extensors, elbow flexors and within muscle groups using pulse durations of 0.2, 1 and 2 ms and stimulation frequencies of 20, 50, 100 and 147 Hz. Extra force production and sustained EMG activity were higher for plantar flexors compared to elbow flexors at all tested parameters (except 0.2 ms for extra force). When compared to elbow flexors, extra force of the knee extensors was only higher at 100 Hz and with 1 ms while sustained EMG activity was higher at all frequencies with pulse durations of 0.2 and 2 ms. Peripheral nerve architecture as well as muscle typology and function could influence the occurrence and magnitude of centrally-mediated responses to NMES. The present findings suggest that the use of wide-pulse high-frequency NMES to promote reflexive recruitment seems to be more pertinent for lower limb muscles, plantar flexors in particular.

Does subthalamic nucleus deep brain stimulation affect the static balance at different frequencies?

PURPOSE

To investigate the effects of bilateral subthalamic nucleus deep brain stimulation (STN-DBS) with different stimulation frequencies on static balance.

MATERIALS AND METHODS

Twenty patients (15 males and 5 females), aged between 43 and 81 (mean: 60.05±7.4) years, who had been diagnosed with idiopathic Parkinson's disease (PD) and undergone STN-DBS surgery were included in the study. Static balance was assessed with TecnoBody Rehabilitation System at four different frequencies: 230, 130, 90 and 60Hz and off-stimulation. Static balance tests were 'stabilometric test, stabilometric compared bipedal closed/opened eye, stabilometric compared mono pedal (right/left foot)'. These tests reported the centre of pressure data 'ellipse area, perimeter, front/back and mediolateral standard deviations'.

RESULTS

There were no statically differences between the static balance test results at any frequency (p>0.05), but results were found better at 90Hz. Stabilometric compared bipedal opened eye forward-backward standard deviation result was significant between off-stimulation and 130Hz (p=0.04). Different frequency stimulation affected the static balance categories percentage with no statistical significance between off-stimulation and others (all p>0.05).

CONCLUSION

This study showed that STN-DBS did not affect the static balance negatively. Low-frequency (LF) stimulation improved the static equilibrium. Posturography systems will give more precise and quantitative results in similar studies with wide frequency ranges.

Effect of 3D paradigm synchronous motion for SSVEP-based hybrid BCI-VR system

A brain-computer interface (BCI) system and virtual reality (VR) are integrated as a more interactive hybrid system (BCI-VR) that allows the user to manipulate the car. A virtual scene in the VR system that is the same as the physical environment is built, and the object's movement can be observed in the VR scene. The four-class three-dimensional (3D) paradigm is designed and moves synchronously in virtual reality. The dynamic paradigm may affect their attention according to the experimenters' feedback. Fifteen subjects in our experiment steered the car according to a specified motion trajectory. According to our online experimental result, different motion trajectories of the paradigm have various effects on the system's performance, and training can mitigate this adverse effect. Moreover, the hybrid system using frequencies between 5 and 10 Hz indicates better performance than those using lower or higher stimulation frequencies. The experiment results show a maximum average accuracy of 0.956 and a maximum information transfer rate (ITR) of 41.033 bits/min. It suggests that a hybrid system provides a high-performance way of brain-computer interaction. This research could encourage more interesting applications involving BCI and VR technologies.

The association of total pulses with the efficacy of repetitive transcranial magnetic stimulation for treatment-resistant major depression: A dose-response meta-analysis

AIM

This study aimed to examine dose-effects of total pulses on improvement of depressive symptoms in patients with treatment-resistant depression (TRD) receiving repetitive transcranial magnetic stimulation (rTMS) over the left dorsal lateral prefrontal cortex (DLPFC).

MATERIALS AND METHODS

The MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, PsycINFO, and ClinicalTrial.gov databases were systematically searched. We included randomized, double-blind, placebo-controlled trials (RCT) that used rTMS over left DLPFC in patients with TRD. Excluded studies were non-TRD, non-RCTs, or combined other brain stimulation interventions. The outcome of interest was the difference between rTMS arms and sham controls in improvement of depressive symptoms in a dose-response manner. A random-effects meta-analysis and dose-response meta-analysis(DRMA) was used to examine antidepressant efficacy of rTMS and association with total pulses.

RESULTS

We found that rTMS over left DLPFC is superior to sham controls (reported as standardized mean difference[SMD] with 95% confidence interval: 0.77; 0.56-0.98). The best-fitting model of DRMA was bell-shaped (estimated using restricted cubic spline model; R2 =0.42), indicating that higher doses (>26,660 total pulses) were not associated with increased improvement of depressive symptoms. Stimulation frequency(R2 =0.53) and age(R2 =0.51) were significant moderators for the dose-response curve. Furthermore, 15-20 Hz rTMS was superior to 10 Hz rTMS (0.61, 0.15-1.10) when combining all doses.

CONCLUSIONS

Our findings suggest higher doses(total pulses) of rTMS were not always associated with increased improvement of depressive symptoms in patients with TRD, and that the dose-response relationship was moderated by stimulation frequency and age. These associations emphasize the importance of determining dosing parameters to achieve maximum efficacy.