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Frey J, Ramirez-Zamora A, Wagle Shukla A. Applications of Transcranial Magnetic Stimulation for Understanding and Treating Dystonia. ADVANCES IN NEUROBIOLOGY 2023; 31:119-139. [PMID: 37338699 DOI: 10.1007/978-3-031-26220-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Transcranial magnetic stimulation (TMS)-based studies have led to an advanced understanding of the pathophysiology of dystonia. This narrative review summarizes the TMS data contributed to the literature so far. Many studies have shown that increased motor cortex excitability, excessive sensorimotor plasticity, and abnormal sensorimotor integration are the core pathophysiological substrates for dystonia. However, an increasing body of evidence supports a more widespread network dysfunction involving many other brain regions. Repetitive TMS pulses (rTMS) in dystonia have therapeutic potential as they can induce local and network-wide effects through modulation of excitability and plasticity. The bulk of rTMS studies has targeted the premotor cortex with some promising results in focal hand dystonia. Some studies have targeted the cerebellum for cervical dystonia and the anterior cingulate cortex for blepharospasm. We believe that therapeutic potential could be leveraged better when rTMS is implemented in conjunction with standard-of-care pharmacological treatments. However, due to several limitations in the studies conducted to date, including small samples, heterogeneous populations, variability in the target sites, and inconsistencies in the study design and control arm, it is hard to draw a definite conclusion. Further studies are warranted to determine optimal targets and protocols yielding the most beneficial outcomes that will translate into meaningful clinical changes.
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Affiliation(s)
- Jessica Frey
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
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Frey J, Hess CW, Kugler L, Wajid M, Wagle Shukla A. Transcranial Magnetic Stimulation in Tremor Syndromes: Pathophysiologic Insights and Therapeutic Role. Front Neurol 2021; 12:700026. [PMID: 34512517 PMCID: PMC8426899 DOI: 10.3389/fneur.2021.700026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/30/2021] [Indexed: 12/12/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) is a painless, non-invasive, and established brain stimulation technique to investigate human brain function. Over the last three decades, TMS has shed insight into the pathophysiology of many neurological disorders. Tremor is an involuntary, rhythmic oscillatory movement disorder commonly related to pathological oscillations propagated via the cerebello-thalamo-cortical pathway. Although tremor is the most common movement disorder and recent imaging studies have enhanced our understanding of the critical pathogenic networks, the underlying pathophysiology of different tremor syndromes is complex and still not fully understood. TMS has been used as a tool to further our understanding of tremor pathophysiology. In addition, repetitive TMS (rTMS) that can modulate brain functions through plasticity effects has been targeted to the tremor network to gain potential therapeutic benefits. However, evidence is available for only a few studies that included small patient samples with limited clinical follow-up. This review aims to discuss the role of TMS in advancing the pathophysiological understanding as well as emerging applications of rTMS for treating individual tremor syndromes. The review will focus on essential tremor, Parkinson's disease tremor, dystonic tremor syndrome, orthostatic tremor, and functional tremor.
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Affiliation(s)
- Jessica Frey
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Christopher W Hess
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Liam Kugler
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Manahil Wajid
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Aparna Wagle Shukla
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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Malone LA, Sun LR. Transcranial Magnetic Stimulation for the Treatment of Pediatric Neurological Disorders. Curr Treat Options Neurol 2019; 21:58. [PMID: 31720969 DOI: 10.1007/s11940-019-0600-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Repetitive transcranial magnetic stimulation (rTMS) is a form of noninvasive brain stimulation that is used for the treatment of migraine and major depression in adults and is now being evaluated for use in other disorders. The purpose of this review is to summarize the physiology underlying TMS, the safety and tolerability in pediatric patients, and the evidence for TMS efficacy in the treatment of pediatric neurologic disorders. RECENT FINDINGS Studies investigating rTMS for adolescent depression, hemiparesis due to pediatric stroke, autism, and tics/Tourette syndrome have demonstrated some therapeutic benefit. rTMS has been insufficiently studied for migraine in children despite benefits demonstrated for adult migraine. Evidence for rTMS in childhood epilepsy and ADHD remains mixed. Repetitive transcranial magnetic stimulation is emerging as a safe, tolerable, and potentially effective therapeutic strategy in a number of pediatric neurological disorders, though high-quality, randomized controlled trials are needed. Ongoing studies should focus on optimization of treatment protocols, development of biomarkers to identify children who will benefit from the technique, and identification of the most appropriate indicators of response.
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Affiliation(s)
- Laura A Malone
- Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Suite 2158, Baltimore, MD, 21287, USA
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Suite 2158, Baltimore, MD, 21287, USA.
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Nascimento GC, Bariotto-dos-Santos K, Leite-Panissi CRA, Del-Bel EA, Bortolanza M. Nociceptive Response to l-DOPA-Induced Dyskinesia in Hemiparkinsonian Rats. Neurotox Res 2018; 34:799-807. [DOI: 10.1007/s12640-018-9896-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/20/2018] [Accepted: 03/22/2018] [Indexed: 12/17/2022]
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Open-Label Fosmetpantotenate, a Phosphopantothenate Replacement Therapy in a Single Patient with Atypical PKAN. Case Rep Neurol Med 2017; 2017:3247034. [PMID: 28567317 PMCID: PMC5439260 DOI: 10.1155/2017/3247034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 03/02/2017] [Accepted: 03/12/2017] [Indexed: 01/22/2023] Open
Abstract
Objective. Pantothenate kinase-associated neurodegeneration (PKAN) is an autosomal recessive disorder with variable onset, rate of progression, and phenotypic expression. Later-onset, more slowly progressive PKAN often presents with neuropsychiatric as well as motor manifestations that include speech difficulties, progressive dystonia, rigidity, and parkinsonism. PKAN is caused by biallelic PANK2 mutations, a gene that encodes pantothenate kinase 2, a regulatory enzyme in coenzyme A biosynthesis. Current therapeutic strategies rely on symptomatic relief. We describe the treatment of the first, later-onset PKAN patient with oral fosmetpantotenate (previously known as RE-024), a novel replacement therapy developed to bypass the enzymatic defect. Methods. This was an open-label, uncontrolled, 12-month treatment with fosmetpantotenate of a single patient with a later-onset, moderately severe, and slowly progressive form of PKAN. Results. The patient showed improvement in all clinical parameters including the Unified Parkinson's Disease Rating Scale (UPDRS), Barry-Albright Dystonia Scale, the EuroQol five-dimensional three-level (EQ-5D-3L) scale, timed 25-foot walk test, and electroglottographic speech analysis. Fosmetpantotenate was well-tolerated with only transient liver enzyme elevation which normalized after dose reduction and did not recur after subsequent dose increases. Conclusions. Fosmetpantotenate showed promising results in a single PKAN patient and should be further studied in controlled trials.
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Krishnan C, Santos L, Peterson MD, Ehinger M. Safety of noninvasive brain stimulation in children and adolescents. Brain Stimul 2014; 8:76-87. [PMID: 25499471 DOI: 10.1016/j.brs.2014.10.012] [Citation(s) in RCA: 160] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/03/2014] [Accepted: 10/21/2014] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Noninvasive brain stimulation (NIBS) techniques such as transcranial magnetic stimulation (TMS) and transcranial current stimulation (tCS) have the potential to mitigate a variety of symptoms associated with neurological and psychiatric conditions, including stroke, cerebral palsy, autism, depression, and Tourette syndrome. While the safety of these modalities has been established in adults, there is a paucity of research assessing the safety of NIBS among children. OBJECTIVE To examine the existing literature regarding the safety of NIBS techniques in children and adolescents with neurologic and neuropsychiatric disorders. METHODS An electronic search was performed on online databases for studies using NIBS in individuals less than 18 years of age. Non-English publications, diagnostic studies, electroconvulsive therapy, single/dual pulse TMS studies, and reviews were excluded. Adverse events reported in the studies were carefully examined and synthesized to understand the safety and tolerability of NIBS among children and adolescents. RESULTS The data from 48 studies involving more than 513 children/adolescents (2.5-17.8 years of age) indicate that the side effects of NIBS were, in general, mild and transient [TMS: headache (11.5%), scalp discomfort (2.5%), twitching (1.2%), mood changes (1.2%), fatigue (0.9%), tinnitus (0.6%); tCS: tingling (11.5%), itching (5.8%), redness (4.7%), scalp discomfort (3.1%)] with relatively few serious adverse events. CONCLUSION Our findings indicate that both repetitive TMS and tCS are safe modalities in children and adolescents with various neurological conditions, especially when safety guidelines are followed. The incidence of adverse events appears to be similar to that observed in adults; however, further studies with longer treatment and follow-up periods are needed to better understand the benefits and tolerance of long-term use of NIBS in children.
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Affiliation(s)
- Chandramouli Krishnan
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Luciana Santos
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Margaret Ehinger
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
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Abstract
Focal dystonias such as writer's cramp or blepharospasm are treatable with botulinum toxin injections and medications, but both therapies provide largely symptomatic relief. Because the basic abnormality in dystonia is at the synaptic level, brain modulating therapies with repetitive transcranial magnetic stimulation (rTMS) may well be able to produce lasting clinical improvement. Low-frequency threshold or subthreshold rTMS over the premotor cortex or anterior cingulate cortex, for hand dystonia and blepharospasm, respectively, could in the future become a more curative treatment, perhaps in conjunction with the current therapies.
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Affiliation(s)
- Kaji Ryuji
- Department of Neurology, Institute of Health-Bioscience, Tokushima University, Tokushima, Japan.
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Abstract
Transcranial magnetic stimulation (TMS) is a neurostimulation and neuromodulation technique that has provided over two decades of data in focal, non-invasive brain stimulation based on the principles of electromagnetic induction. Its minimal risk, excellent tolerability and increasingly sophisticated ability to interrogate neurophysiology and plasticity make it an enviable technology for use in pediatric research with future extension into therapeutic trials. While adult trials show promise in using TMS as a novel, non-invasive, non-pharmacologic diagnostic and therapeutic tool in a variety of nervous system disorders, its use in children is only just emerging. TMS represents an exciting advancement to better understand and improve outcomes from disorders of the developing brain.
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Schneider SA, Dusek P, Hardy J, Westenberger A, Jankovic J, Bhatia KP. Genetics and Pathophysiology of Neurodegeneration with Brain Iron Accumulation (NBIA). Curr Neuropharmacol 2013; 11:59-79. [PMID: 23814539 PMCID: PMC3580793 DOI: 10.2174/157015913804999469] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 06/06/2012] [Accepted: 07/03/2012] [Indexed: 01/19/2023] Open
Abstract
Our understanding of the syndromes of Neurodegeneration with Brain Iron Accumulation (NBIA) continues to grow considerably. In addition to the core syndromes of pantothenate kinase-associated neurodegeneration (PKAN, NBIA1) and PLA2G6-associated neurodegeneration (PLAN, NBIA2), several other genetic causes have been identified (including FA2H, C19orf12, ATP13A2, CP and FTL). In parallel, the clinical and pathological spectrum has broadened and new age-dependent presentations are being described. There is also growing recognition of overlap between the different NBIA disorders and other diseases including spastic paraplegias, leukodystrophies and neuronal ceroid lipofuscinosis which makes a diagnosis solely based on clinical findings challenging. Autopsy examination of genetically-confirmed cases demonstrates Lewy bodies, neurofibrillary tangles, and other hallmarks of apparently distinct neurodegenerative disorders such as Parkinson's disease (PD) and Alzheimer's disease. Until we disentangle the various NBIA genes and their related pathways and move towards pathogenesis-targeted therapies, the treatment remains symptomatic. Our aim here is to provide an overview of historical developments of research into iron metabolism and its relevance in neurodegenerative disorders. We then focus on clinical features and investigational findings in NBIA and summarize therapeutic results reviewing reports of iron chelation therapy and deep brain stimulation. We also discuss genetic and molecular underpinnings of the NBIA syndromes.
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Affiliation(s)
- Susanne A Schneider
- Department of Neurology; University of Kiel, 24105 Kiel, Germany
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, UK
| | - Petr Dusek
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - John Hardy
- Department of Molecular Neuroscience, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, England
| | - Ana Westenberger
- Schilling Section of Clinical and Molecular Neurogenetics at the Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, UK
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Schneider SA, Bhatia KP. Syndromes of neurodegeneration with brain iron accumulation. Semin Pediatr Neurol 2012; 19:57-66. [PMID: 22704258 DOI: 10.1016/j.spen.2012.03.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In parallel to recent developments of genetic techniques, understanding of the syndromes of neurodegeneration with brain iron accumulation has grown considerably. The acknowledged clinical spectrum continues to broaden, with age-dependent presentations being recognized. Postmortem brain examination of genetically confirmed cases has demonstrated Lewy bodies and/or tangles in some forms, bridging the gap to more common neurodegenerative disorders, including Parkinson disease. In this review, the major forms of neurodegeneration with brain iron accumulation (NBIA) are summarized, concentrating on clinical findings and molecular insights. In addition to pantothenate kinase-associated neurodegeneration (PKAN) and phospholipase A2-associated neurodegeneration (PLAN), fatty acid hydroxylase-associated neurodegeneration (FAHN) NBIA, mitochondrial protein-associated neurodegeneration, Kufor-Rakeb disease, aceruloplasminemia, neuroferritinopathy, and SENDA syndrome (static encephalopathy of childhood with neurodegeneration in adulthood) are discussed.
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Affiliation(s)
- Susanne A Schneider
- Schilling Section of Clinical and Molecular Neurogenetics, Department of Neurology, University of Lübeck, Lübeck, Germany.
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Schneider SA, Hardy J, Bhatia KP. Syndromes of neurodegeneration with brain iron accumulation (NBIA): An update on clinical presentations, histological and genetic underpinnings, and treatment considerations. Mov Disord 2011; 27:42-53. [DOI: 10.1002/mds.23971] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 08/09/2011] [Accepted: 08/15/2011] [Indexed: 11/07/2022] Open
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Huang YZ, Rothwell JC, Lu CS, Wang J, Chen RS. Restoration of motor inhibition through an abnormal premotor-motor connection in dystonia. Mov Disord 2010; 25:696-703. [PMID: 20309999 DOI: 10.1002/mds.22814] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
To clarify the rationale for using rTMS of dorsal premotor cortex (PMd) to treat dystonia, we examined how the motor system reacts to an inhibitory form of rTMS applied to the PMd in healthy subjects and in a group of patients with focal hand dystonia and DYT1 gene carriers. Continuous theta burst transcranial magnetic stimulation (cTBS) with 300 and 600 pulses (cTBS300 and cTBS600) was applied to PMd, and its after-effects were quantified by measuring the amplitude of MEPs evoked by single pulse transcranial magnetic stimulation (TMS) over the primary motor cortex (M1), short interval intracortical inhibition/facilitation (SICI/ICF) within M1, the third phase of spinal reciprocal inhibition (RI), and writing tests. In addition, in DYT1 gene carriers, the effects of cTBS300 over M1 and PMd on MEPs were studied in separate experiments. In healthy subjects, cTBS300 and cTBS600 over PMd suppressed MEPs for 30 min or more and cTBS600 decreased SICI and RI. In contrast, neither form of cTBS over PMd had any significant effect on MEPs, while cTBS600 increased effectiveness of SICI and RI and improved writing in patients with writer's cramp. NMDYT1 had a normal response to cTBS300 over left PMd. We suggest that the reduced PMd to M1 interaction in dystonic patients is likely to be due to reduced excitability of PMd-M1 connections. The possible therapeutic effects of premotor rTMS may therefore involve indirect effects of PMd on SICI and RI, which this study has shown can be normalised by cTBS.
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Affiliation(s)
- Ying-Zu Huang
- Department of Neurology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taipei, Taiwan
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