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Di Lazzaro V, Ranieri F, Bączyk M, de Carvalho M, Dileone M, Dubbioso R, Fernandes S, Kozak G, Motolese F, Ziemann U. Novel approaches to motoneuron disease/ALS treatment using non-invasive brain and spinal stimulation: IFCN handbook chapter. Clin Neurophysiol 2024; 158:114-136. [PMID: 38218077 DOI: 10.1016/j.clinph.2023.12.012] [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: 10/13/2023] [Revised: 11/28/2023] [Accepted: 12/17/2023] [Indexed: 01/15/2024]
Abstract
Non-invasive brain stimulation techniques have been exploited in motor neuron disease (MND) with multifold objectives: to support the diagnosis, to get insights in the pathophysiology of these disorders and, more recently, to slow down disease progression. In this review, we consider how neuromodulation can now be employed to treat MND, with specific attention to amyotrophic lateral sclerosis (ALS), the most common form with upper motoneuron (UMN) involvement, taking into account electrophysiological abnormalities revealed by human and animal studies that can be targeted by neuromodulation techniques. This review article encompasses repetitive transcranial magnetic stimulation methods (including low-frequency, high-frequency, and pattern stimulation paradigms), transcranial direct current stimulation as well as experimental findings with the newer approach of trans-spinal direct current stimulation. We also survey and discuss the trials that have been performed, and future perspectives.
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Affiliation(s)
- Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy.
| | - Federico Ranieri
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Marcin Bączyk
- Department of Neurobiology, Poznań University of Physical Education, Królowej Jadwigi Street 27/39, 61-871 Poznań, Poland
| | - Mamede de Carvalho
- Institute of Physiology, Institute of Molecular Medicine-JLA, Egas Moniz Study Centre, Faculty of Medicine, University of Lisbon, Lisbon 1649-028, Portugal; Department of Neurosciences and Mental Health, CHULN, Lisbon, Portugal
| | - Michele Dileone
- Faculty of Health Sciences, UCLM Talavera de la Reina, Toledo, Spain; Neurology Department, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Raffaele Dubbioso
- Neurophysiology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Napoli, Italy
| | - Sofia Fernandes
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências, Universidade de Lisboa, Campo Grande, 1749-016-Lisboa, Portugal
| | - Gabor Kozak
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Francesco Motolese
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Ulf Ziemann
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany.
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Nikolov P, Zimmermann JV, Hassan SS, Albrecht P, Schnitzler A, Groiss SJ. Impact of the number of conditioning pulses on motor cortex excitability: a transcranial magnetic stimulation study. Exp Brain Res 2020; 239:583-589. [PMID: 33373012 PMCID: PMC7936961 DOI: 10.1007/s00221-020-06010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/07/2020] [Indexed: 12/03/2022]
Abstract
Conditioning transcranial magnetic stimulation (TMS) with subthreshold conditioning stimulus followed by supra-threshold test stimulus at inter-stimulus intervals (ISI) of 1–5 ms results in inhibition (SICI), while ISI at 10–15 ms results in facilitation (ICF). One concerning issue, applying ICF/SICI protocols on patients is the substantial protocol variability. Here, we hypothesized that increasing the number of CS could result in more robust ICF/SICI protocols. Twenty healthy subjects participated in the study. Motor-evoked potentials (MEP) were obtained from conditioning TMS with a varying number of conditioning stimuli in 3, 4, 10, and 15 ms ISI over the primary motor cortex. MEP amplitudes were then compared to examine excitability. TMS with 3, 5, and 7 conditioning stimuli but not with one conditioning stimulus induced ICF. Moreover, 10 ms ISI produced stronger ICF than 15 ms ISI. Significant SICI was only induced with one conditioning stimulus. Besides, 3 ms ISI resulted in stronger SICI than 4 ms ISI. Only a train of conditioning stimuli induced stable ICF and may be more advantageous than the classical paired pulse ICF paradigm.
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Affiliation(s)
- Petyo Nikolov
- Institute of Clinical Neuroscience and Medical Psychology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Johanna V Zimmermann
- Institute of Clinical Neuroscience and Medical Psychology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Shady S Hassan
- Department of Neurology, Medical Faculty, Assiut University Hospital, Assiut, Egypt
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Institute of Clinical Neuroscience and Medical Psychology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan J Groiss
- Institute of Clinical Neuroscience and Medical Psychology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
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Tokimura R, Murakami T, Ugawa Y. Central motor conduction time reveals upper motor neuron involvement masked by lower motor neuron impairment in a significant portion of patients with amyotrophic lateral sclerosis. Clin Neurophysiol 2020; 131:1896-1901. [PMID: 32593964 DOI: 10.1016/j.clinph.2020.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/13/2020] [Accepted: 05/03/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We retrospectively investigated the utility of the central motor conduction time (CMCT) in detecting upper motor neuron (UMN) involvements in patients with amyotrophic lateral sclerosis (ALS). METHODS Fifty-two ALS patients and 12 disease control patients participated in this study. Surface electromyograms were recorded from the first dorsal interosseous (FDI) and tibialis anterior (TA) muscles. We stimulated the motor cortex, brainstem, and spinal nerve using transcranial magnetic stimulation (TMS) in order to measure the cortical, brainstem, and spinal latencies. We divided the ALS patients into 2 subgroups (with UMN impairment vs. without UMN impairment) and calculated the rates of abnormal CMCT prolongation judged by their comparison with the normal ranges obtained by the measurement in the control patients. RESULTS The CMCTs in the FDI and TA were abnormally prolonged in over 40% of the ALS patients with UMN impairment and in nearly 30% of those without UMN impairment. CONCLUSIONS CMCT shows UMN dysfunction in ALS patients without clinical UMN impairment. SIGNIFICANCE TMS still has diagnostic utility in a significant portion of ALS patients.
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Affiliation(s)
- Ryo Tokimura
- Department of Neurology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan.
| | - Takenobu Murakami
- Department of Neurology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan; Department of Neurology, Tottori Prefectural Kousei Hospital, 150 Higashishowacho, Kurayoshi, Japan
| | - Yoshikazu Ugawa
- Department of Neurology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan; Department of Human Neurophysiology, Fukushima Medical University, 1 Hikarigaoka, Fukusima, Japan
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Hassan SS, Trenado C, Rageh TA, Schnitzler A, Groiss SJ. Effect of conditioning and test stimulus intensity on cortical excitability using triad-conditioning transcranial magnetic stimulation. Exp Brain Res 2020; 238:1305-1309. [PMID: 32322929 PMCID: PMC7237525 DOI: 10.1007/s00221-020-05812-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 04/13/2020] [Indexed: 01/17/2023]
Abstract
Cortical facilitation assessed with triad conditioning transcranial magnetic stimulation has been termed triad-conditioned facilitation (TCF). TCF has been supposed to reflect increased intracortical facilitation (ICF) at short interstimulus intervals (ISI) around 10 ms and an intrinsic rhythm of the motor cortex at longer ISI around 25 ms. To gain further insight into the pathophysiological mechanism of TCF, we systematically studied the effect of suprathreshold conditioning stimulus (CS) and test stimulus (TS) intensity on TCF. Various CS intensities and TS intensities were used in a triad-conditioning paradigm that was applied to 11 healthy subjects. ISI between pulses were studied between 5 and 200 ms. TCF at 10 ms ISI enhanced with increasing CS intensity but decreased with increasing TS intensity. The duration of facilitation was longer with higher CS intensity. However, TCF at 25 ms ISI could not be elicited with none of the CS and TS intensities addressed here. Our results are consistent with the notion of TCF at short ISI reflecting ICF. The enhanced and prolonged facilitation with increase of CS without additional isolated facilitation at longer ISI suggest a prolongation of ICF.
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Affiliation(s)
- Shady Safwat Hassan
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- Department of Neurology, Assiut University Hospital, Assiut, Egypt
| | - Carlos Trenado
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- Translational Neuromodulation Unit, Department of Psychology and Neurosciences, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Dortmund, Germany
| | - Tarek Ali Rageh
- Department of Neurology, Assiut University Hospital, Assiut, Egypt
| | - Alfons Schnitzler
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstr 5, 40225, Düsseldorf, Germany
| | - Stefan Jun Groiss
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstr 5, 40225, Düsseldorf, Germany.
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Superconditioning TMS for examining upper motor neuron function in MND. Exp Brain Res 2019; 237:2087-2103. [PMID: 31175383 DOI: 10.1007/s00221-019-05573-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/30/2019] [Indexed: 01/09/2023]
Abstract
We used transcranial magnetic stimulation (TMS) of motor cortex, including a novel four-pulse superconditioning (TMSsc) paradigm, in repeated examinations of motor-evoked potentials (MEPs) in eight subjects with motor neuron disease (MND), including seven with amyotrophic lateral sclerosis (ALS). The goals were: (1) to look for evidence of cortical hyperexcitability, including a reduction in short-interval intracortical inhibition (SICI); and (2) to examine the utility of using TMSsc for quantifying upper motor neuron function during MND progression. Testing of abductor pollicis brevis (APB) and tibialis anterior (TA) muscles bilaterally was carried out every 3 months in MND subjects for up to 2 years; results were compared to those from a cohort of 15 control subjects. Measures of SICI were not significantly different between control and MND subjects for either APB or TA muscles. Other measures of cortical excitability, including TMS threshold and MEP amplitude, were consistent with lowered cortical excitability in MND subjects. Certain combinations of superconditioning TMS were capable of causing stronger inhibition or facilitation of MEPs compared to dual-pulse TMS, for both APB and TA target muscles. Moreover, there were multiple cases in which target muscles unresponsive to strong single-pulse TMS, whether at rest or when tested with an active contraction, showed an MEP in response to TMSsc optimized for facilitation. Our findings suggest that a multi-faceted neurophysiologic protocol for examining upper motor neuron function in MND subjects might benefit from inclusion of TMSsc testing.
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