Navigated transcranial magnetic stimulation of the supplementary motor cortex disrupts fine motor skills in healthy adults

Permanent deterioration of fine motor skills after the resection of tumors in the supplementary motor area

Supplementary motor area syndrome (SMAS) represents a common neurosurgical sequela. The incidence and time frame of its occurrence have yet to be characterized after surgery for brain tumors. We examined patients suffering from a brain tumor preoperatively, postoperatively, and during follow-up examinations after three months, including fine motor skills testing and transcranial magnetic stimulation (TMS). 13 patients suffering from a tumor in the dorsal part of the superior frontal gyrus underwent preoperative, early postoperative, and 3-month follow-up testing of fine motor skills using the Jebsen-Taylor Hand Function Test (JHFT) and the Nine-Hole Peg Test (NHPT) consisting of 8 subtests for both upper extremities. They completed TMS for cortical motor function mapping. Test completion times (TCTs) were recorded and compared. No patient suffered from neurological deficits before surgery. On postoperative day one, we detected motor deficits in two patients, which remained clinically stable at a 3-month follow-up. Except for page-turning, every subtest indicated a significant worsening of function, reflected by longer TCTs (p < 0.05) in the postoperative examinations for the contralateral upper extremity (contralateral to the tumor manifestation). At 3-month follow-up examinations for the contralateral upper extremity, each subtest indicated significant worsening compared to the preoperative status despite improvement to the immediate postoperative level. We also detected significantly longer TCTs (p < 0.05) postoperatively in the ipsilateral upper extremity. This study suggests a long-term worsening of fine motor skills even three months after SMA tumor resection, indicating the necessity of targeted physical therapy for these patients.

Mapping of the supplementary motor area using repetitive navigated transcranial magnetic stimulation

Background

The supplementary motor area (SMA) is important for motor and language function. Damage to the SMA may harm these functions, yet tools for a preoperative assessment of the area are still sparse.

Objective

The aim of this study was to validate a mapping protocol using repetitive navigated transcranial magnetic stimulation (rnTMS) and extend this protocol for both hemispheres and lower extremities.

Methods

To this purpose, the SMA of both hemispheres were mapped based on a finger tapping task for 30 healthy subjects (35.97 ± 15.11, range 21-67 years; 14 females) using rnTMS at 20 Hz (120% resting motor threshold (RMT)) while controlling for primary motor cortex activation. Points with induced errors were marked on the corresponding MRI. Next, on the identified SMA hotspot a bimanual finger tapping task and the Nine-Hole Peg Test (NHPT) were performed. Further, the lower extremity was mapped at 20 Hz (140%RMT) using a toe tapping task.

Results

Mean finger tapping scores decreased significantly during stimulation (25.70taps) compared to baseline (30.48; p < 0.01). Bimanual finger tapping led to a significant increase in taps during stimulation (28.43taps) compared to unimanual tapping (p < 0.01). Compared to baseline, completion time for the NHPT increased significantly during stimulation (baseline: 13.6 s, stimulation: 16.4 s; p < 0.01). No differences between hemispheres were observed.

Conclusion

The current study validated and extended a rnTMS based protocol for the mapping of the SMA regarding motor function of upper and lower extremity. This protocol could be beneficial to better understand functional SMA organisation and improve preoperative planning in patients with SMA lesions.

Protocol for mapping of the supplementary motor area using repetitive navigated transcranial magnetic stimulation

Background

Damage to the supplementary motor area (SMA) can lead to impairments of motor and language function. A detailed preoperative mapping of functional boarders of the SMA could therefore aid preoperative diagnostics in these patients.

Objective

The aim of this study was the development of a repetitive nTMS protocol for non-invasive functional mapping of the SMA while assuring effects are caused by SMA rather than M1 activation.

Methods

The SMA in the dominant hemisphere of 12 healthy subjects (28.2 ± 7.7 years, 6 females) was mapped using repetitive nTMS at 20 Hz (120% RMT), while subjects performed a finger tapping task. Reductions in finger taps were classified in three error categories (≤15% = no errors, 15-30% = mild, >30% significant). The location and category of induced errors was marked in each subject's individual MRI. Effects of SMA stimulation were then directly compared to effects of M1 stimulation in four different tasks (finger tapping, writing, line tracing, targeting circles).

Results

Mapping of the SMA was possible for all subjects, yet effect sizes varied. Stimulation of the SMA led to a significant reduction of finger taps compared to baseline (BL: 45taps, SMA: 35.5taps; p < 0.01). Line tracing, writing and targeting of circles was less accurate during SMA compared to M1 stimulation.

Conclusion

Mapping of the SMA using repetitive nTMS is feasible. While errors induced in the SMA are not entirely independent of M1, disruption of the SMA induces functionally distinct errors. These error maps can aid preoperative diagnostics in patients with SMA related lesions.

Contribution of neural circuits tested by transcranial magnetic stimulation in corticomotor control of low back muscle: a systematic review

Introduction

Transcranial magnetic stimulation (TMS) is widely used to investigate central nervous system mechanisms underlying motor control. Despite thousands of TMS studies on neurophysiological underpinnings of corticomotor control, a large majority of studies have focused on distal muscles, and little is known about axial muscles (e.g., low back muscles). Yet, differences between corticomotor control of low back and distal muscles (e.g., gross vs. fine motor control) suggest differences in the neural circuits involved. This systematic review of the literature aims at detailing the organisation and neural circuitry underlying corticomotor control of low back muscles tested with TMS in healthy humans.

Methods

The literature search was performed in four databases (CINAHL, Embase, Medline (Ovid) and Web of science) up to May 2022. Included studies had to use TMS in combination with EMG recording of paraspinal muscles (between T12 and L5) in healthy participants. Weighted average was used to synthesise quantitative study results.

Results

Forty-four articles met the selection criteria. TMS studies of low back muscles provided consistent evidence of contralateral and ipsilateral motor evoked potentials (with longer ipsilateral latencies) as well as of short intracortical inhibition/facilitation. However, few or no studies using other paired pulse protocols were found (e.g., long intracortical inhibition, interhemispheric inhibition). In addition, no study explored the interaction between different cortical areas using dual TMS coil protocol (e.g., between primary motor cortex and supplementary motor area).

Discussion

Corticomotor control of low back muscles are distinct from hand muscles. Our main findings suggest: (i) bilateral projections from each single primary motor cortex, for which contralateral and ipsilateral tracts are probably of different nature (contra: monosynaptic; ipsi: oligo/polysynaptic) and (ii) the presence of intracortical inhibitory and excitatory circuits in M1 influencing the excitability of the contralateral corticospinal cells projecting to low back muscles. Understanding of these mechanisms are important for improving the understanding of neuromuscular function of low back muscles and to improve the management of clinical populations (e.g., low back pain, stroke).

Hemispheric Differences of 1 Hz rTMS over Motor and Premotor Cortex in Modulation of Neural Processing and Hand Function

INTRODUCTION

Non-invasive brain stimulation can modulate both neural processing and behavioral performance. Its effects may be influenced by the stimulated area and hemisphere. In this study (EC no. 09083), repetitive transcranial magnetic stimulation (rTMS) was applied to the primary motor cortex (M1) or dorsal premotor cortex (dPMC) of either the right or left hemisphere, while evaluating cortical neurophysiology and hand function.

METHODS

Fifteen healthy subjects participated in this placebo-controlled crossover study. Four sessions of real 1 Hz rTMS (110% of rMT, 900 pulses) over (i) left M1, (ii) right M1, (iii) left dPMC, (iv) right dPMC, and one session of (v) placebo 1 Hz rTMS (0% of rMT, 900 pulses) over the left M1 were applied in randomized order. Motor function of both hands (Jebsen-Taylor Hand Function Test (JTHFT)) and neural processing within both hemispheres (motor evoked potentials (MEPs), cortical silent period (CSP), and ipsilateral silent period (ISP)) were evaluated prior and after each intervention session.

RESULTS

A lengthening of CSP and ISP durations within the right hemisphere was induced by 1 Hz rTMS over both areas and hemispheres. No such intervention-induced neurophysiological changes were detected within the left hemisphere. Regarding JTHFT and MEP, no intervention-induced changes ensued. Changes of hand function correlated with neurophysiological changes within both hemispheres, more often for the left than the right hand.

CONCLUSIONS

Effects of 1 Hz rTMS can be better captured by neurophysiological than behavioral measures. Hemispheric differences need to be considered for this intervention.

Gray Matter Abnormalities in Patients with Complex Regional Pain Syndrome: A Systematic Review and Meta-Analysis of Voxel-Based Morphometry Studies

Current findings on brain structural alterations in complex regional pain syndrome (CRPS) are heterogenous and controversial. This study aimed to perform a systematic review and meta-analysis to explore the significant gray matter volume (GMV) abnormalities between patients with CRPS and healthy controls (HCs). A systematic search of the PubMed, Web of Science, and MEDLINE databases was performed, updated through 27 January 2022. A total of five studies (93 CRPS patients and 106 HCs) were included. Peak coordinates and effect sizes were extracted and meta-analyzed by anisotropic effect size-signed differential mapping (AES-SDM). Heterogeneity, sensitivity, and publication bias of the main results were checked by the Q test, jackknife analysis, and the Egger test, respectively. Meta-regression analysis was performed to explore the potential impact of risk factors on GMV alterations in patients with CRPS. The main analysis exhibited that patients with CRPS had increased GMV in the left medial superior frontal gyrus (SFGmedial.L), left striatum, and an undefined area (2, 0, -8) that may be in hypothalamus, as well as decreased GMV in the corpus callosum (CC) (extending to right supplementary motor area (SMA.R), right median cingulate/paracingulate gyri (MCC.R)), and an undefined area (extending to the right caudate nucleus (CAU.R), and right thalamus (THA.R)). Meta-regression analysis showed a negative relationship between increased GMV in the SFGmedial.L and disease duration, and the percentage of female patients with CRPS. Brain structure abnormalities in the sensorimotor regions (e.g., SFGmedial.L, SMA.R, CAU.R, MCC.R, and THA.R) may be susceptible in patients with CRPS. Additionally, sex differences and disease duration may have a negative effect on the increased GMV in SFGmedial.L.

Topography of Movement-Related Delta and Theta Brain Oscillations

The aim of this study was to analyse the high density EEG during movement execution guided by visual attention to reveal the detailed topographic distributions of delta and theta oscillations. Twenty right-handed young subjects performed a finger tapping task, paced by a continuously transited repeating visual stimuli. Baseline corrected power of scalp current density transformed EEG was statistically assessed with cluster-based permutation testing. Delta and theta activities revealed differences in their spatial properties at the time of finger tapping execution. Theta synchronization showed a contralateral double activation in the parietal and fronto-central regions, while delta activity appeared in the central contralateral channels. Differences in the spatiotemporal topography between delta and theta activity in the course of movement execution were identified on high density EEG.

Primary hand motor representation areas in healthy children, preadolescents, adolescents, and adults

The development of the organization of the motor representation areas in children and adolescents is not well-known. This cross-sectional study aimed to provide an understanding for the development of the functional motor areas of the upper extremity muscles by studying healthy right-handed children (6-9 years, n = 10), preadolescents (10-12 years, n = 13), adolescents (15-17 years, n = 12), and adults (22-34 years, n = 12). The optimal representation site and resting motor threshold (rMT) for the abductor pollicis brevis (APB) were assessed in both hemispheres using navigated transcranial magnetic stimulation (nTMS). Motor mapping was performed at 110% of the rMT while recording the EMG of six upper limb muscles in the hand and forearm. The association between the motor map and manual dexterity (box and block test, BBT) was examined. The mapping was well-tolerated and feasible in all but the youngest participant whose rMT exceeded the maximum stimulator output. The centers-of-gravity (CoG) for individual muscles were scattered to the greatest extent in the group of preadolescents and centered and became more focused with age. In preadolescents, the CoGs in the left hemisphere were located more laterally, and they shifted medially with age. The proportion of hand compared to arm representation increased with age (p = 0.001); in the right hemisphere, this was associated with greater fine motor ability. Similarly, there was less overlap between hand and forearm muscles representations in children compared to adults (p<0.001). There was a posterior-anterior shift in the APB hotspot coordinate with age, and the APB coordinate in the left hemisphere exhibited a lateral to medial shift with age from adolescence to adulthood (p = 0.006). Our results contribute to the elucidation of the developmental course in the organization of the motor cortex and its associations with fine motor skills. It was shown that nTMS motor mapping in relaxed muscles is feasible in developmental studies in children older than seven years of age.

Inhibition of the supplementary motor area affects distribution of effort over time

In tasks that extend over time, people tend to exert much effort at the beginning and the end, but not in the middle, exhibiting the stuck-in-the-middle pattern (STIM). To date, little is known about the neural mechanisms underlying this effect. As the supplementary motor area (SMA) was previously implicated in coding prospective task-demands, we tested its role in producing the STIM pattern. Participants first underwent an SMA-localization session in which they tapped their fingers repeatedly while fMRI-scanned. In the next two sessions, before playing a 10-min computer game that measured effort-engagement, participants underwent inhibitory 1-Hz repetitive transcranial magnetic stimulation over the SMA, or over a control precuneus location. Three control experiments and a pretest confirmed that this task yields a STIM, which can be eliminated when the task lacks a salient end-point, or is too short. The results of the main experiment showed a more pronounced STIM following inhibitory SMA stimulation compared to control. A control analysis showed that overall level of effort was similar in both conditions, rendering alternative accounts in terms of motor inhibition unlikely. These findings are consistent with the possibility that the SMA may play a role in moment-to-moment coding of effort value, or in related sub-processes, which can cause effort to be distributed more equally over the course of a task.