Evidence-Based Guidelines and Secondary Meta-Analysis for the Use of Transcranial Direct Current Stimulation in Neurological and Psychiatric Disorders

Effects of antagonistic network-targeted tDCS on brain co-activation patterns depends on the networks' electric field: a simultaneous tDCS-fMRI study

BACKGROUND

Brain networks should be ideal targets for non-invasive brain stimulation, as network dysfunction is a common feature of various neuropsychiatric disorders. Understanding the mechanisms of network-targeted stimulation is essential for advancing its clinical applications.

MATERIAL AND METHOD

The current study utilized simultaneous network-targeted transcranial direct current stimulation(tDCS) and functional magnetic resonance imaging (fMRI) to investigate the effects of tDCS targeting antagonistic networks on brain dynamics. A total of 143 healthy participants were recruited and assigned to receive central executive network (CEN)-targeted tDCS (C-targeted group), default mode network (DMN)-targeted tDCS (D-targeted group), or sham tDCS (sham group). fMRI data with three sections (pre-stimulation, during-stimulation, post-stimulation) were collected across all subjects. Individual electric field (EF) strength was simulated using individual head model. Six recurring brain patterns (co-activation patterns, CAPs) were identified. The temporal indices of these CAPs (occurrence, fraction time, persistence time) and their transition probabilities were calculated. This study first examined the effects of C-targeted / D-targeted / sham tDCS on temporal indices and further explored the contribution of brain networks' EF strength on the altered temporal indices.

RESULTS

C-targeted tDCS significantly increased the temporal indices of CAPs dominated by DMN and the transition probabilities from other CAPs to DMN-dominated CAPs during stimulation. Meanwhile, the decreased temporal indices of CAP dominated by CEN, and its transition probabilities to these CAPs were also found during C-targeted tDCS. In contrast, the D-targeted tDCS had only a slight effect on brain dynamics, while sham tDCS showed no significant impact. Further fusion analyses revealed that the EF strength in the salience network made a large contribution to the temporal indices of CAPs during stimulation, highlighting tight interactions within the triple networks. Moreover, integrating the EF strength of networks with large contributions and the pre-stimulation temporal indices effectively predicted the temporal indices of CAPs during stimulation. These findings suggest that C-targeted tDCS can modulate brain dynamics and emphasize the critical role of networks' EF during stimulation.

CONCLUSION

This study demonstrates the effectiveness and feasibility of network-targeted tDCS in modulating brain dynamics, providing a new choice for treating neuropsychiatric disorders characterized by aberrant brain dynamics.

Neural mass modelling of brain stimulation to Alleviate Schizophrenia biomarkers in brain rhythms

We present a neural mass model (NMM) of the brain thalamo-cortico-thalamic (TCT) network to understand the effectiveness of non-invasive treatment with transcranial Direct Current Stimulation (tDCS) in reversing the anomalous electroencephalogram (EEG) oscillations in Schizophrenia. Our TCT NMM consists of twelve neural populations representing the thalamus and cortex modules of the visual pathway connected in a closed loop; the synaptic pathways are modelled with a 3-state kinetic framework allowing the inclusion of the slow excitatory N-methyl-D-aspartate-receptors (NMDAR). Indeed, a popular hypothesis in Schizophrenia is the hypofunction of the Glutamatergic neurotransmitter receptors, NMDAR, associated with the inhibitory Gamma-amino-butyric-acid (GABA-)ergic populations in the cortex, leading to anomalous brain oscillations. Experimental studies simulate the EEG conditions in Schizophrenia by administering sub-anesthetic dosage of Ketamine, which blocks NMDAR channels at the Magnesium binding sites. We could simulate the Ketamine-induced NMDAR channel blocking by varying the Magnesium concentration in the 3-state synaptic models of appropriate pathways. Our results show Ketamine-induced increased excitatory behaviour in the model output; the changes in the γ and σ band oscillations conform to experimental studies. A model to factor in the neuroplasticity effects of applying tDCS (after (Riedinger and Hutt, 2022)) is interfaced with the TCT NMM. Informed by experimental literature, the simulated extrinsic current induced by tDCS is set to affect the plasticity in selected pathways. With appropriate parameterisation, we could simulate the reversal of the Ketamine-induced altered EEG oscillations. Overall, our in silico study emphasises the potential of NMM in predicting protocols for tDCS towards effective personalised treatment of Schizophrenia.

Effect of Anodal Transcranial Direct Current Stimulation on the Intensity of Post-dural Puncture Headache: Results of Two Randomized Sham Controlled Trials

INTRODUCTION

Post-dural puncture headache (PDPH) is a common complication of diagnostic lumbar puncture (LP), often leading to extended hospitalization and additional medication use. Clinical studies have shown that anodal transcranial direct current stimulation (a-tDCS) is effective against migraine, and thus we decided to assess whether a-tDCS was also effective in treating and preventing PDPH.

METHODS

In two independent, randomized, monocentric controlled trials (RCTs), we enrolled 97 hospitalized participants who underwent LP for diagnostic purposes. Patients were randomized to receive either active a-tDCS or sham tDCS over the dominant primary motor cortex (M1) in a therapeutic tDCS (Th-tDCS) or preventive tDCS (Pr-tDCS) study. In the two trials, the primary outcome was the severity of PDPH measured using the Visual Analogue Scale (VAS) for pain. Secondary outcomes included the Brief Pain Inventory (BPI) to evaluate other pain-related symptoms associated with LP.

RESULTS

In the Th-tDCS study, significant differences between groups were observed after tDCS in the VAS (F = 17.011, p < 0.001), as well as in BPI intensity (F = 17.006, p < 0.001) and BPI interference (F = 14.730, p < 0.001). Moreover, in the Pr-tDCS study, VAS analysis showed a significant time × group interaction (F = 6.918, p = 0.002). Significant differences were also observed in BPI intensity (F = 17.866, p < 0.001) and BPI interference (F = 15.520, p < 0.001).

CONCLUSIONS

Our findings suggest that a-tDCS may effectively prevent and treat PDPH and alleviate other pain-related symptoms associated with LP. Encouraging results have emerged for the use of a-tDCS in patients undergoing LP, in both experimental research designs (Th-tDCS and Pr-tDCS). A non-invasive brain stimulation (NIBS) technique, such as a-tDCS, could have a therapeutic and preventive effect on pain resulting from a LP.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT06640634) retrospectively registered on October 8, 2024.

Churning Better Transcranial Direct Current Stimulation Outcome with Accelerated Protocols: Understanding the Non-linear Dynamics through Metaplasticity

Recent advances in the application of transcranial direct current stimulation in psychiatry include providing about five sessions of stimulation in a short period of time with an inter-session interval of 20 minutes. Such "accelerated" protocols may reduce treatment duration and have differential neurophysiological benefits. In this narrative review, we discuss the potential impact of such protocols on the temporal aspects of metaplasticity of the neurons, non-linear behaviour of the neuronal population and brain criticality. We discuss the potential neurophysiological mechanisms involved and how to translate these mechanisms to specific stimulation parameters like duration of session, inter-session interval and number of sessions in a day. The expected benefits and necessary precautions required for accelerated protocols are also discussed.

Longitudinal Effects of Transcranial Direct Current Stimulation on Daily Rejection-Related Emotions in Borderline Personality Disorder: An Ecological Momentary Assessment Study Protocol

BACKGROUND

Borderline Personality Disorder (BPD) is a debilitating mental health condition characterized by emotional dysregulation and interpersonal dysfunction, with perceived social rejection exacerbating these issues. Emerging evidence suggests that a single session of transcranial direct current stimulation (tDCS) over the right ventrolateral prefrontal cortex (rVLPFC) may decrease the unique tendency of BPD patients to feel rejected even when socially included during a laboratory task.

OBJECTIVES

This protocol outlines a double-blind, sham-controlled study evaluating the longitudinal effects of repeated anodal tDCS over the right ventrolateral prefrontal cortex (rVLPFC) on rejection-related emotions (RRE) during real-life social interactions in individuals with BPD.

METHODS

Sixty BPD patients will be randomized to receive real or sham tDCS across 10 daily sessions, coupled with an ecological momentary assessment (EMA) protocol capturing emotional and behavioral responses to real-life social interactions over four timepoints: baseline, during treatment, ten days post-treatment, and three months post-treatment. Primary outcomes include changes in RRE, with exploratory analyses examining feelings of social connection, aggressive tendencies, trust toward others, and interpersonal and affective dynamics. Multilevel modeling will assess temporal and group-level effects. Expected Results and Impact: This study aims to establish the efficacy of tDCS in reducing BPD patients' negative emotional response in real-life social situations and to determine whether such effects are maintained in time. The findings could advance the clinical application of tDCS as an adjunctive intervention to alleviate social-emotional impairments in BPD, addressing gaps in current treatment approaches and guiding future research into the neural mechanisms of social emotion regulation.

A Comparative Analysis of Technical Data: At-Home vs. In-Clinic Application of Transcranial Direct Current Stimulation in Depression

OBJECTIVE

The application of transcranial direct current stimulation (tDCS) at home for the treatment of depression and other neuropsychiatric disorders presents both significant opportunities and inherent challenges. Ensuring safety and maintaining high-quality stimulation are paramount for the efficacy and safety of at-home tDCS. This study investigates tDCS quality based on its technical parameters as well as safety of at-home and in-clinic tDCS applications comparing the data from two randomized controlled trials in patients with major depressive disorder.

METHODS

We analyzed 229 active stimulation sessions from the HomeDC study (at-home tDCS) and 835 sessions from the DepressionDC study (in-clinic tDCS). Notably, five adverse events (skin lesions) were reported exclusively in the at-home cohort, highlighting the critical need for enhanced safety protocols in unsupervised environments.

RESULTS

The analysis revealed a significant difference in the average variability of impedances between at-home and in-clinic applications (F1,46 = 4.96, p = .031, η2 = .097). The at-home tDCS sessions exhibited higher impedance variability (M = 837, SD = 328) compared to in-clinic sessions (M = 579, SD = 309). Furthermore, at-home tDCS sessions resulting in adverse events (AEs) were associated with significantly higher average impedances than sessions without such issues.

CONCLUSION

The study demonstrates that monitoring the technical parameters of at-home tDCS used in this study is essential. However, it may be not sufficient for ensuring safety and promptly detecting or preventing adverse events. Quality control protocols including digital training and monitoring techniques should be systematically developed and tested for a reliable and safe application of at-home tDCS therapies.

Diagnosis, evaluation & management of cognitive disorders in Parkinson's disease: A systematic review

BACKGROUND

There is considerable variability in the diagnosis, evaluation and management of cognitive disorders in Parkinson's disease (PD) across clinical services. A review of guidelines and relevant literature will provide recommendations to guide clinical decision-making. The present review aimed to summarise and critically appraise current recommendations for the diagnosis, evaluation and management of cognitive disorders in PD.

METHOD

Five academic databases (PubMed, SCOPUS, Medline, PsycINFO, CINAHL) and five grey literature databases were systematically searched in August 2024 by two independent reviewers following PRISMA guidelines. Guidelines and systematic reviews from 2003-2024 available in English and reporting at least one relevant recommendation for the diagnosis, evaluation or management of cognitive disorders in PD were included. Quality assessment was completed using the AGREE-II tool for guidelines and AMSTAR tool for systematic reviews.

RESULTS

In total, 32 guidelines and 24 systematic reviews were included. Guideline quality ranged from moderate to high and systematic review quality from critically low to high. Articles provided recommendations for cognitive impairment in PD in terms of diagnosis, neuropsychological evaluation, treatment and care. However, recommendations for cognitive tools, care considerations, and non-pharmacological interventions were limited, despite relevant evidence from the systematic review literature.

CONCLUSION

Significant gaps identified in processes for neuropsychological evaluations, inconsistent recommendations for non-pharmacological interventions, and limited care considerations calls for future iterations of the clinical practice guidelines for cognitive impairment in PD.

Effects of dual-target repetitive transcranial magnetic stimulation in patients with minimally conscious state: A preliminary study

Repetitive transcranial magnetic stimulation (rTMS) is a promising neuromodulation therapy that facilitates recovery in patients with prolonged disorders of consciousness (pDOC). This study aimed to evaluate the efficacy of dual-target rTMS in treating patients with minimally conscious state (MCS). A total of 20 MCS patients were recruited and randomly assigned to either the real or sham stimulation group. Participants received 10 Hz rTMS targeting the left prefrontal and parietal cortices for 10 consecutive days. The Coma Recovery Scale-Revised (CRS-R) and resting-state EEG were recorded, with relative power spectral density and coherence subsequently computed. Additionally, behavioral assessments were conducted over a six-month follow-up period. Our findings indicate that 10 Hz dual-target rTMS enhances brain oscillatory activity in the frontal, central, and parietal lobes. Specifically, the treatment resulted in a reduction in delta-band activity and an increase in alpha-band activity in the frontal lobes, as well as an elevation in alpha-band power in the central and parietal region. In contrast, no significant changes were observed in the sham stimulation group. Meanwhile, in the real stimulation group, long-distance coherence (F3-P4) exhibited increased in alpha-band. These findings suggest that enhanced oscillatory activity and EEG functional connectivity may underlie the modulatory effects of dual-target rTMS. Additionally, a combined prefrontal and parietal cortex approach is another viable option in rTMS protocols for patients with pDOC.

Modulation of dopaminergic transmission and brain activity by frontotemporal tDCS: A multimodal PET-MR imaging study

BACKGROUND

Transcranial Direct Current Stimulation (tDCS) is a promising noninvasive intervention for schizophrenia, particularly when applied using a frontotemporal montage. Although significant clinical benefits have been reported, the variability in individual responses underscores the need for a more comprehensive understanding of its underlying neurophysiological mechanisms. Here, we used a simultaneous positron emission tomography (PET) and magnetic resonance imaging (MRI) approach (PET-MR) to investigate the effects of frontotemporal tDCS on dopamine transmission, cerebral perfusion, and white matter microstructural integrity in healthy individuals.

METHODS

In a double-blind, two-arm, parallel group study, 30 healthy volunteers were randomly allocated to receive a single session of either active (n = 15) or sham (n = 15) frontotemporal tDCS. The stimulation session was delivered during simultaneous multimodal PET-MR imaging, which combined PET with the [11C]raclopride radiotracer, Arterial Spin Labeling (ASL), and Diffusion Weighted Imaging.

RESULTS

PET [11C]raclopride analysis revealed a significant reduction in Non-Displaceable Binding Potential in the left executive striatal subregion 15 min after tDCS in the active group, compared to both baseline and the sham group. This finding suggests that frontotemporal tDCS may induce an increase in dopamine release. ASL analysis showed that active tDCS may reduce cerebral blood flow in the precuneus compared to sham stimulation. No significant effects of tDCS were observed on white matter microstructural integrity.

CONCLUSION

This study provides new insights into the neurophysiological mechanisms of frontotemporal tDCS, paving the way for the optimization of therapeutic strategies for patients with dysregulated cortico-subcortical dopamine systems.

A Single Session of tDCS Stimulation Can Modulate an EEG Microstate Associated With Anxiety in Patients With Depression

PURPOSE

Microstate analysis involves examining the temporal dynamics of electroencephalogram (EEG) signals and serves as a crucial method for exploring the neural basis of psychiatric disorders. This study investigates the effects of transcranial direct current stimulation (tDCS) on specific microstate parameter maps-D and C in patients with depression, specifically targeting the dorsomedial prefrontal cortex (DMPFC) and left dorsolateral prefrontal cortex (DLPFC).

METHODS

We conducted an open-label, between-subject, crossover trial involving 19 patients clinically diagnosed with depression. A 1 mA electrical current was administered, with anodal stimulation specifically targeting the DMPFC or the left DLPFC. Microstate maps were derived from resting-state EEG recordings obtained prior to and following the application of tDCS. The EEG data were categorized into five distinct microstate classes for subsequent analysis.

FINDINGS

The findings revealed a significant increase in the duration of microstate class D following stimulation in both groups, while microstate class C exhibited no notable changes. Additionally, a significant association was identified between the transition from microstate D to C and alterations in the State-Trait Anxiety Inventory-State (STAI-S) scores after left DLPFC stimulation.

CONCLUSION

Microstate map D appears to be associated with psychiatric disorders and executive functions, whereas map C may relate to the salience network and mind-wandering. Our findings suggest that microstate maps D and C are responsive to tDCS stimuli, indicating their potential as objective tools for anxiety assessment. Employing transition-focused parameters in EEG microstate analysis may enhance the tracking of rapidly fluctuating emotional states, rather than relying solely on duration metrics. Furthermore, the integration of non-invasive brain stimulation techniques, such as tDCS, with EEG microstate analysis holds significant promise for elucidating the neural mechanisms involved in depression.

TRIAL REGISTRATION

UMIN-CTR Clinical Trial: UMIN000015046.

Impact of Transcranial Direct Current Stimulation on Dual-Task Gait Performance in Parkinson's Disease: A Systematic Review

BackgroundParkinson's disease (PD) impairs motor and cognitive functions, increasing fall risk during dual-task activities. While transcranial direct current stimulation (tDCS), a non-invasive brain stimulation technique, has been studied for improving these functions in PD, its effect on dual-task gait remains unclear.ObjectiveThis review aims to evaluate the effects of tDCS on dual-task gait performance in PD.MethodsA systematic search was conducted in PubMed, Embase, and Web of Science for studies published before September 2024. Eligible studies included PD patients, used tDCS, and measured dual-task gait performance. Two researchers independently assessed methodological quality using the Cochrane Risk of Bias tool.ResultsFour randomized controlled trials and four crossover studies, involving 222 PD patients (mean age 64.17 years, range 50.9-72) at Hoehn & Yahr stages 1-3, met the inclusion criteria. Three of six studies targeting the dorsolateral prefrontal cortex showed significant improvements in dual-task gait performance, particularly in gait speed (p ≤ 0.046), compared to sham. No significant improvements were observed with primary motor cortex or cerebellar stimulation (all p's ≥ 0.100).ConclusionstDCS targeting the dorsolateral prefrontal cortex may improve dual-task gait performance in PD, but further studies are needed to refine protocols and confirm its therapeutic potential.

Boosting and maintaining the response to transcranial direct current stimulation (tDCS) in schizophrenia with persistent hallucinations: A retrospective exploratory study from a naturalistic clinical cohort

BACKGROUND

Transcranial direct current stimulation (tDCS) may help to alleviate persistent auditory hallucinations (AH) in schizophrenia, though its effects vary. This study examines the effectiveness, replicability and tolerance of booster and maintenance tDCS courses administered to patients with schizophrenia in a naturalistic clinical setting after an initial tDCS course.

METHODS

Thirty-three patients received booster course(s) (after symptom relapse) and/or maintenance courses (to prevent relapse) following an initial course of 2-15 days. Linear mixed-effect (LME) model and intra-class correlation (ICC) evaluated the differences and consistency of percentage improvement in AH across the initial and booster courses. The duration between the initial and the first booster course served as a proxy for time to relapse, with its relationship to clinical and demographic measures analyzed using Pearson's correlation.

RESULTS

The booster course was safely administered in 33 patients, 22 weeks after the initial course. AH improved significantly in 20 patients. The improvement percentages for the initial (43.6 %) and the booster courses (29.3 %) had an ICC of 0.711 (95 %CI:0.372-0.868, p < 0.001), suggesting moderate replicability of effects. The LME model revealed that course type and number of tDCS sessions significantly influenced improvement. Maintenance tDCS was administered in 5 patients at 1-4 week intervals, with 2 maintaining improvement.

CONCLUSION

This study offers insights into the likely duration of initial tDCS effects and highlights the utility of booster courses for individuals who responded to the initial treatment. The study suggests the possibility of using maintenance tDCS in patients who have responded to the initial or booster treatments.

Reduction of rejection-related emotions by transcranial direct current stimulation over right ventrolateral prefrontal cortex in borderline personality disorder: A double-blind randomized pilot study

AIMS

Borderline personality disorder (BPD) patients show negative emotional reactions to both excluding and including social scenarios, with levels normalizing only during extreme inclusion. Prior research among healthy individuals highlights the right ventrolateral prefrontal cortex (rVLPFC) role in regulating emotional responses to social exclusion, since transcranial direct current stimulation (tDCS) of rVLPFC decreases rejection-related emotions following social exclusion. This pilot study investigated whether, in BPD patients, tDCS over the rVLPFC reduces rejection-related emotions not only after social exclusion but also after fair social inclusion.

METHODS

Forty BPD patients randomly received either real or sham tDCS on rVLPFC before participating in the Cyberball paradigm, which involved phases of inclusion, exclusion, and over-inclusion. Participants self-reported their level of rejection-related emotions following each phase.

RESULTS

Transcranial direct current stimulation reduced rejection-related emotions during both social exclusion and fair inclusion, but not during over-inclusion. Specifically, those in the Real tDCS group exhibited comparable emotional responses to fair and over-including scenarios, unlike those in the Sham group who experienced heightened rejection-related emotions during fair inclusion compared to over-inclusion.

CONCLUSIONS

Transcranial direct current stimulation over the rVLPFC reduces BPD patients' tendency to feel rejected both in fairly including and excluding scenarios. These findings confirm the rVLPFC involvement in emotional regulation and highlight a therapeutic potential for tDCS in moderating BPD's typical heightened rejection-related emotional responses to fairly including scenarios. This study supports the application of tDCS in BPD treatment, providing new insights into neuromodulatory interventions that can aid BPD patients to better regulate their emotions during varying social scenarios.

Therapeutic approach to fibromyalgia: a consensus statement on pharmacological and non-pharmacological treatment from the neuropathic pain special interest group of the Italian neurological society

BACKGROUND

Although fibromyalgia is a disabling disease, there is no targeted therapy for specific neurotransmitters or inflammatory mediators. Our aim was to provide neurologists with practical guidance for the management of these difficult patients based on a critical, narrative and non-systematic review of randomized controlled trials (RCTs) from the last 10 years.

METHODS

The members of the Special Interest Group Neuropathic Pain of the Italian Neurological Society evaluated the randomized controlled trials (RCTs) of the last 10 years and answered questions that allow a consensus on the main pharmacological and non-pharmacological approaches.

RESULTS

The neuropathic pain working group agreed on prescribing antiepileptic drugs or antidepressants in the case of comorbidities with anxiety and depression. As a second choice, experts have agreed on the association of antiepileptics and antidepressants, while they disagree with the use of opioids. Medical cannabis and nutraceuticals are promising new treatment options, although more data is needed to prove their efficacy. The neurologists agreed in suggesting physical activity at the first visit, particularly aerobic and strength training. As a second choice, they considered a cognitive behavioral therapy approach to be useful.

CONCLUSIONS

Pharmacologic treatment with antiepileptic drugs and antidepressants in patients with co-occurring anxiety and depression, as well as an early nonpharmacologic approach based primarily on physical activity, may be a useful indication in contemporary neurology clinical practice. Non-pharmacological options, such as cognitive behavioral therapy and non-invasive brain stimulation NIBS, could improve evidence of efficacy and lead to relevant improvement in FM-related disability.

Efficacy of CBT, intensified tDCS and their combination for reducing clinical symptoms and improving quality of life in social anxiety disorder with comorbid depression: a randomized controlled trial

BACKGROUND/AIM

Social anxiety disorder (SAD) is a common and disabling psychiatric disorder. It is generally treated with medication and psychotherapy such as cognitive-behavioral therapy (CBT). Due to the involvement of cortical and subcortical areas in the pathophysiology of SAD, non-invasive brain stimulation techniques such as transcranial Direct Current Stimulation (tDCS) are potential adjunctive treatment options for SAD. This study aims to assess comparable efficacy of CBT, intensified tDCS, and combined CBT/tDCS on clinical symptoms and quality of life of patients with SAD and comorbid depression.

METHODS

In this randomized controlled trial, 37 adults with SAD and comorbid depressive disorder were assigned into three groups: (1) CBT + active tDCS (n = 13), (2) active tDCS alone (n = 12), and (3) CBT + sham tDCS (n = 12). SAD symptoms, depressive states, quality of life and trait worry were assessed with the Liebowitz Social Anxiety Scale, Beck's Depression Inventory, QOL questionnaire (WHOQOL-BREF), and the Penn State Worry Questionnaire respectively. The active tDCS was an intensified stimulation protocol (20 min, twice-daily sessions with 20 min intervals, 5 consecutive days) and was applied over the left dorsolateral prefrontal cortex (F3) and medial prefrontal cortex (Fpz). The CBT was provided individually based on the exposure technique at 12-20 sessions, twice a week. All clinical measures were assessed at baseline, after the intervention, and at 3-month follow-up.

RESULTS

SAD symptoms significantly decreased after intervention and follow-up in all groups, with no significant differences between them. However, CBT + tDCS resulted in a numerically larger symptom reduction, significantly exceeding CBT + sham tDCS on the fear scale. Depressive states and trait worry significantly improved in all groups post-intervention and at the 3-month follow-up, with no between-group differences. Quality of life (total scores, physical, and psychological domains) significantly improved after the and at the 3-month follow-up only in the CBT + tDCS and tDCS-alone groups with no between-group differences.

CONCLUSION

Psychotherapeutic interventions​ with CBT, intensified tDCS targeting the prefrontal cortex, and the combined CBT-tDCS are effective for alleviating primary and secondary clinical symptoms in individuals with SAD. The combined CBT-tDCS intervention showed superior efficacy in reducing the primary symptoms of SAD.

TRIAL REGISTRATION ID

IRCT20220421054607N1, registration date: 19/05/2022, available at: https://irct.behdasht.gov.ir/trial/63119 .

Effects of transcranial direct current stimulation on motor and cognitive function in paediatric brain damage: a systematic review and meta-analysis

PURPOSE

Transcranial direct current stimulation (tDCS) emerges as a secure therapy in paediatric brain damage rehabilitation. Our purpose is to acknowledge its evidence in motor and cognitive variables, examine correlations between tDCS effects and parameters, and identify associations between motor and cognitive outcomes.

METHODS

A systematic review and meta-analysis were conducted, registered in PROSPERO (CRD42023448441). 5 databases were consulted in September 2024. Randomised controlled trials evaluating tDCS effectiveness on motor or cognitive outcomes in paediatric brain injuries were included. Methodological quality was assessed using PEDro scale and ROB-2. Certainty of evidence was assessed by GRADE.

RESULTS

Nineteen studies were selected (447 participants). tDCS seems to be beneficial in gait (SMD: 0.83-0.90 (p < 0.0001)), balance (COP oscillations SMD: -0.51 - -1.13 (p < 0.02), PBS SMD: 0.48-0.56 (p < 0.0001)), functionality (SMD: 0.40 (p < 0.01)). Effects on cognition showed promising results. Effects in upper limb are controversial, due to fewer publications.

CONCLUSIONS

tDCS seems beneficial in motor and cognitive functions in paediatric brain damage. Motor and cognitive functions appears to be interconnected, so combined protocols could be an effective approach. Meta-analysis results are promising but may be considered carefully as few articles could be included. Further research is needed.

Delayed Effects of tDCS Combined with Cognitive Behavioral Therapy in Major Depression: A Randomized, Double-Blind Pilot Trial

AIMS

This pilot study assessed the potential psychosocial and therapeutic impacts of augmenting transcranial direct current stimulation (tDCS) with cognitive behavioral therapy (CBT) in treatment-naïve patients diagnosed with major depressive disorder (MDD).

METHODS

In this double-blind randomized controlled trial, 10 subjects were randomized into two groups-CBT with active tDCS (active tDCS; n = 6; M = 33.3 years; 4 females) or CBT with sham tDCS (Sham; n = 4; M = 31.2 years; 2 females). Severity of depression was measured with the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Beck Depression Inventory (BDI). Participants' secondary outcomes included life satisfaction, sleep quality, and anxiety symptoms. They were assessed at baseline, following treatment (week 6), and at 2, 4, 8, and 12-week follow-ups.

RESULTS

By week 12, the active tDCS group's BDI scores showed greater improvement relative to the sham group. There were also significant differences between groups over time in MADRS scores. Sleep quality also improved in the active tDCS group, with many participants achieving symptom-free status-defined as BDI scores of 9 or less and supported by consistently low MADRS scores-by the end of the follow-up period.

CONCLUSIONS

These preliminary data indicate that the combination of tDCS with CBT may optimize the treatment of MDD through depressive symptom relief and improved sleep, while also prolonging the benefits of treatment.

Prefrontal cortex stimulation prevents stress-induced HPA axis reactivity in people at familial risk of schizophrenia

BACKGROUND

Schizophrenia is a multifactorial disorder with a range of risk factors. Dysregulation in the systems involved in the stress response is a key component of its pathophysiology. Individuals at risk of developing schizophrenia exhibit hyperreactivity to stress and altered cognitive performance, both known as vulnerability markers. This study aims to determine whether stimulation of the prefrontal cortex can reduce reactivity to stress in unaffected siblings of patients with schizophrenia.

METHODS

In a randomized, sham-controlled trial, 27 participants were assigned to receive either active (n = 14) or sham (n = 13) transcranial direct current stimulation (tDCS) over the prefrontal cortex for 30 min during exposure to an acute stressor. The stress response was measured biologically, via salivary cortisol levels, and cognitively, through a reality monitoring task, which serves as an intermediate cognitive vulnerability marker.

RESULTS

In contrast to the sham condition, active stimulation significantly reduced cortisol release in response to stress (F(9,216) = 1.972; p = 0.04) and prevented stress-induced impairment in reality monitoring (F(1,23) = 9.954; p = 0.004).

CONCLUSIONS

These findings suggest that tDCS should be a promising tool for reducing stress-induced biological and cognitive reactivity in a population at risk of schizophrenia.

Anodal transcranial direct current stimulation combined with physical exercise increases postural sway in Parkinson's disease: a double-blind and cross-over study

Transcranial direct current stimulation (tDCS) has shown promising effects on postural control in people with Parkinson's disease (PwPD). However, the characteristics of the stimulation, such as the specific cortical area targeted and combination with exercise, seem to influence the tDCS effects. Therefore, analyzing these factors is essential for identifying key characteristics and optimizing rehabilitation protocols for postural control in PD.We aimed to analyze the efficacy of tDCS over the primary motor (M1) and pre-frontal cortices (PFC) combined with aerobic exercise on postural control in PwPD. Twenty-one PwPD participated in this crossover, randomized, and double-blind study. The intervention consisted of exercising on a treadmill at moderate intensity for 30 min while receiving the stimulation. tDCS was applied during the central 20 min of exercise over M1, PFC, or sham on 3 different days. Three one-minute trials were conducted with participants standing still on a force platform to assess the center of pressure parameters in anteroposterior (AP) and mediolateral (ML) directions in pre- and post-intervention. Time*stimulation interaction was observed for sway area (p = 0.038) and sway mean amplitude in both the AP (p = 0.009) and ML directions (p = 0.059, marginal effect). Post-hoc analysis indicated a larger sway area and mean amplitude in both directions post-intervention compared to pre-intervention after tDCS application to the M1 and PFC. No significant differences were observed for the sham condition. Our findings suggest that the combination of exercise and tDCS, regardless of the area stimulated, modifies postural control in PwPD, leading to a larger sway.

An Update on the Use of Neuromodulation Strategies in the Treatment of Schizophrenia

The field of neuromodulation has evolved tremendously and now includes a vast array of interventions utilizing different technologies that span electrical, magnetic, and ultrasound forms of stimulation. The evolution of interventions holds the promise of fewer adverse effects and a noninvasive approach, increasing the scale at which these interventions may be offered in hospital and community settings. While the majority of neuromodulation studies have focused on patients with mood disorders, predominantly depression, there is an unmet need for patients with schizophrenia, who are in dire need of novel therapeutic options. Advances in neuroimaging and approaches for examining individual variability and transdiagnostic symptoms may lead to more effective neuromodulation treatments in this patient population. This overview explores the modern landscape of invasive and noninvasive neuromodulation treatments for patients with schizophrenia. It begins with approaches that involve diffuse stimulation of the cortex and subcortex and then reviews more focal stimulation approaches at the cortical and subcortical levels. The authors also reflect on the relationship between our understanding of the neurobiology of schizophrenia and neuromodulation interventions.

Local effective connectivity changes after transcranial direct current stimulation in obsessive-compulsive disorder patients

AIM

This study investigates the effects of transcranial direct current stimulation (tDCS) on brain network connectivity in individuals with obsessive-compulsive disorder (OCD).

METHODS

In a randomized, double-blind, sham-controlled experimental design anodal tDCS (vs. sham) was applied in a total of 43 right-handed patients with OCD, targeting the right pre-supplementary motor area (pre-SMA). Cathodal reference electrode was put on the left pre-SMA. The current was set as 2 mA, with a stimulation duration of either 30 s (sham) or 1200 s. Concurrent resting-state functional MRI data were collected following tDCS (or sham) stimulation. We employed regression dynamic causal modelling (rDCM) to extract whole brain effective connectivity (EC) matrices subsequently analyzing these matrices through graph theory approaches to examine changes in brain activity across different network scales.

RESULTS

We found that tDCS compared to sham caused significant changes in local effective connectivity. Increased recruitment level was detectable in the sensorimotor network (SMN), indicating enhanced intra-network connectivity after active tDCS. Clustering coefficient and local efficiency were also found to be increased in the same area. No significant changes were detectable with regard to global network connectivity.

CONCLUSIONS

Current findings indicate that single-session tDCS can effectively alter local effective connectivities within the SMN in OCD patients. Given the relevance of the SMN and connected regions for the pathophysiology of OCD we believe that tDCS targeting these areas might constitute an effective intervention to normalize altered network connectivity in the disorder of OCD.

LIMITATION

We used a single tDCS session, which may not reflect long-term effects.

Diagnosis and Management of Early Stages of ALD

Early forms of alcohol-associated liver disease (ALD) include different stages in the progression of compensated liver disease ranging from steatosis to steatohepatitis and fibrosis. ALD has been classically diagnosed at advanced stages more frequently than other liver diseases. This fact probably contributed to the scarcity of studies on early forms of ALD. Recent studies have investigated the prevalence of early ALD in the general population and have described the natural history of alcohol-induced steatosis and fibrosis, which have been linked to worse prognosis compared with early stages of other chronic liver diseases. In addition, studies on screening and early diagnosis of ALD in at-risk populations have shown that these strategies allow early detection and intervention. Of note, up to 28% of the United States population has concurrent alcohol use and metabolic syndrome, and estimated prevalence of advanced fibrosis among heavy drinkers with metabolic syndrome has increased from 3% in the 1990s to more than 10% in the 2010s. Therefore, new challenges and treatment opportunities will emerge for patients with ALD. In this review, we provide an overview of the state of the art in early ALD, focusing on natural history, diagnosis, and management, and provide insights into future perspectives.

Learning from missteps: Potential of transcranial electrical stimulation in neuropsychological rehabilitation

Transcranial electrical stimulation (tES) holds promise for neuropsychological rehabilitation by leveraging the brain's inherent plasticity to enhance cognitive and motor functions. However, early results have been variable due to oversimplified approaches. This manuscript explores the potential and complexities of tES, particularly focusing on a protocol defined transcranial direct current stimulation as a reference model for all tES protocols, emphasising the need for precision in tailoring stimulation parameters to individual characteristics. By integrating intrinsic (i.e. the neuro-physiological system state) and extrinsic factors (i.e. experimental set up), highlighting the critical role of state-dependent effects and the synergy with cognitive tasks, we aim to refine tES protocols. This approach not only addresses the complexity of the brain system (as defined by its current state) but also highlights the importance of collaborative research and data sharing to understand the underlying mechanisms of tES-induced changes and optimising therapeutic efficacy. Emphasising the integration of tES with targeted tasks and clearer hypotheses, this work underscores the potential for more effective neurorehabilitation strategies.

The non-invasive brain or nerve stimulation treatment did not increase seizure frequency in patients with epilepsy: A network meta-analysis

The noninvasive brain and nerve stimulation (NIBNS) treatments had been widely applied in numerous psychiatric diseases. They exerted preferable efficacy and had been considered as an alternative or add-on treatment to the traditional pharmacotherapy. However, the risk of complication of seizure had seized the clinicians so that they feared about this potential complication. Actually, the NIBNS techniques have emerged as an alternative adjunctive treatment method for patients with epilepsy. However, the results of randomized controlled trials (RCTs) investigating the ability of NIBNS to reduce the frequency of seizures have been inconclusive. The aim of the current network meta-analysis (NMA) was to compare the efficacy and acceptability of various NIBNS techniques for reducing the frequency of seizures in patients with epilepsy. This frequentist model-based NMA included RCTs of NIBNS techniques for patients with epilepsy. The primary outcomes were seizure frequency change and acceptability (i.e., dropout rate). This NMA of 20 RCTs indicated that only 2-mA cathodal short-duration transcranial direct current stimulation (hc-sd-c-tDCS) was associated with significantly greater reduction in seizure frequency and significantly greater improvement in quality of life than the sham/control. Further, none of the investigated NIBNS techniques had significantly increased seizure frequency compared with the sham/control. In addition, all the investigated NIBNS techniques were associated with similar acceptability with the sham/control. Our results indicated that none of the investigated NIBNS techniques was associated with an increased risk of epileptic seizure.

tDCS Combined with CIMT for Post-stroke Upper Extremity Rehabilitation: A Systematic Review and Meta-Analysis

BackgroundTranscranial direct current stimulation (tDCS) has been widely used as an adjunctive treatment for motor function after stroke.ObjectiveTo quantify the effect of tDCS combined with constraint-induced movement therapy (CIMT) on the functional recovery of the upper limb after stroke.MethodsBy May 2024, two independent authors screened relevant randomized controlled trials (RCTs) published in English from PubMed, Embase, Web of Science and the Cochrane Library. Publication bias was assessed using the Egger's test.ResultsOf the 221 retrieved records, seven publications met the criteria for systematic review and quantitative analysis. According to estimates of Hedges'g, significant effects were revealed from Fugl-Meyer Assessment for Upper Limbs (UL-FMA) for upper limb impairment (g = 0.587, 95% CI = 0.256 to 0.919, p < 0.05) and Motor Activity Log-Amount of Movement (MAL-AoM) for perceived amount of motor (g = 0.386, 95% CI = 0.030 to 0.743, p < 0.05). Significant results favoring combined therapy were not found in Motor Activity Log-Quality of Movement (MAL-QoM) (g = 0.181, 95% CI = -0.169 to 0.531, p > 0.05), grip strength (g = 0.135, 95% CI = -0.214 to 0.485, p > 0.05) or Wolf Motor Function Test (WMFT) (g = 0.210, 95% CI = -0.117 to 0.537, p > 0.05).ConclusionsOur findings confirmed that tDCS enhanced the effect of CIMT in improving upper limb impairment and perceived amount of motor in daily life after stroke.

Examining tolerability, safety, and blinding in 1032 transcranial electrical stimulation sessions for children and adolescents with neuropsychiatric and neurodevelopmental disorders

The present study first extensively evaluated the tolerability, safety, and blinding of transcranial direct current stimulation (tDCS) and transcranial random noise stimulation (tRNS) in paediatric clinical populations, composed of 92 children and adolescents (54 females, age range: 8-17 years), involving 1032 sessions across neuropsychiatric (i.e., anorexia nervosa) and neurodevelopmental (i.e., attention deficit and hyperactivity disorder, developmental dyscalculia) conditions. It compared adverse events (AEs) occurrence between active and sham transcranial electrical stimulation (tES) conditions (i.e., 528 active vs. 504 sham sessions) as well as tDCS and tRNS (i.e., 772 tDCS sessions vs. 260 tRNS sessions), while considering demographic and emotional-behavioural factors. Results showed tES safety with no "moderate" or "severe" AEs reported; about 77% of sessions were AE-free, supporting tES use in these populations. Itching was the most common symptom, and active sessions were found to be more likely to induce AEs compared to sham sessions. Notably, tRNS had a higher AE likelihood than tDCS, possibly due to experimental differences. In the current study, demographic and emotional-behavioural variables did not significantly affect AEs. Blinding procedures were moderately effective, with about half of participants correctly identifying their condition. As indicated in prior studies, tRNS seems to better preserve blinding integrity. In conclusion, this study provides comprehensive insights into tES tolerability and safety in paediatric clinical populations, emphasizing the need for further AEs exploration in tES and blinding procedure refinement in future research.

Home-based transcranial direct current stimulation paired with cognitive training to reduce fatigue in multiple sclerosis

Fatigue is a common and often debilitating feature of multiple sclerosis (MS) that lacks reliably effective treatment options for most patients. Transcranial direct current stimulation (tDCS), a safe and well-tolerated type of noninvasive brain stimulation, is a low-cost and home-based approach with the potential to reduce fatigue in MS. We conducted a double-blind, sham-controlled, randomized clinical trial to compare active vs. low-dose (sham) tDCS paired with computer-based cognitive training, delivered as a home-based intervention, to reduce MS-related fatigue. Participants with MS-related fatigue, but without depression, were stratified by neurologic disability using the Extended Disability Status Scale (EDSS) and randomized to complete 30 daily sessions over six weeks of either active or sham tDCS paired with online cognitive training (BrainHQ). The primary outcome was the change in PROMIS Fatigue score from baseline to the end of the intervention. A total of 117 participants were randomized, with 92% completing all treatment sessions. Both groups showed significant reductions in fatigue, with no significant difference between them. This suggests that tDCS does not provide any additional benefit over cognitive training alone in reducing fatigue, but confirms the feasibility and tolerance of this home-based intervention.

Efficacy of brain stimulation therapies across psychiatric, movement, and cognitive disorders: an umbrella review synthesizing meta-analyses of randomized controlled trials

BACKGROUND

Brain stimulation therapy (BST) has significant potential in treating psychiatric, movement, and cognitive disorders. Given the high prevalence of comorbidities among these disorders, we conducted an umbrella review to comprehensively assess the efficacy of BSTs in treating the core symptoms across these three categories of disorders.

METHODS

We systematically searched for meta-analyses and network meta-analyses of randomized controlled trials with sham controls up to September 25, 2024, from databases including PubMed, PsycINFO, Embase, and the Cochrane Library. Our primary outcome was improvements in core symptoms. We evaluated quality using 11 criteria. We calculated pooled effect estimates for core symptoms based on the largest meta-analyses, then conducted sensitivity and subgroup analyses, and assessed heterogeneity, publication bias, and small-study effects. Finally, we synthesized effect sizes from all meta-analyses to provide a comprehensive overview of BSTs' efficacy. PROSPERO registration: CRD42023439090.

FINDINGS

We included 198 articles with 108,377 patients evaluating 14 BSTs across 21 disorders. The largest meta-analysis showed a moderate standardized mean difference (SMD) of 0.56 (95% CI: 0.49, 0.64; I2 = 70%). Subgroup analyses revealed significant SMDs for psychiatric disorders (0.60; 95% CI: 0.49, 0.71; I2 = 66%), movement disorders (0.56; 95% CI: 0.42, 0.69; I2 = 79%), and cognitive disorders (0.46; 95% CI: 0.32, 0.61; I2 = 48%). SMDs were 0.44 (95% CI: 0.23, 0.65; I2 = 70%) for follow-up ≤1 month and 0.69 (95% CI: 0.43, 0.94; I2 = 84%) for follow-up >1 month. Compared to other conditions, BSTs show better therapeutic effects in treating depression, post-traumatic stress disorder, obsessive-compulsive disorder, pain, fibromyalgia, and post-stroke motor recovery.

INTERPRETATION

This review explored the potential of BSTs for comorbidities of the three disorders from a disorder-specific perspective, providing a roadmap for their clinical application and future research.

FUNDING

This work was supported by the Anhui Natural Science Foundation (2023AH040086), Key Laboratory of Philosophy and Social Science of Anhui Province on Adolescent Mental Health and Crisis Intelligence Intervention (SYS2023B08), and the Joint Funds of the National Natural Science Foundation of China (U23A20424).

Repetitive transcranial magnetic stimulation for fibromyalgia: are we there yet?

Repetitive transcranial magnetic stimulation (rTMS) has increasingly been used to modify cortical maladaptive plastic changes shown to occur in fibromyalgia (FM) and to correlate with symptoms. Evidence for its efficacy is currently inconclusive, mainly due to heterogeneity of stimulation parameters used in trials available to date. Here, we reviewed the current evidence on the use of rTMS for FM control in the format of a narrative review, in which a systematic dissection of the different stimulation parameters would be possible. We conducted a search in Medline and Embase for controlled trials on rTMS in people with FM with at least 10 participants in each treatment arm, and treatment/follow-up of at least 3 weeks. The search identified 482 abstracts, of which 45 were screened to full review, and 11 met inclusion criteria. Six out of 11 trials were positive. The dorsolateral prefrontal cortex was the target in 218 patients (49.2%), and the primary motor cortex (M1) in 225 (50.8%). Studies targeting M1 at 10 Hz, with stimulation current delivered in the posterior-anterior, were systematically positive, frequently showing that maintenance sessions delivered weekly, and biweekly were able to maintain the analgesic effects seen after daily induction sessions. Studies assessing the effects of rTMS for FM are still marked by heterogeneity in stimulation petameters, choice of primary outcomes, and inclusion criteria. The selection of the stimulation parameters associated with significant analgesic effects is likely to benefit following larger multicenter trials and improve the overall management of pain and associated symptoms in people with FM.

Research progress of tDCS in the treatment of ADHD

TDCS is one of the most widely used non-invasive neuromodulation techniques, which changes the excitability of local cortical tissue by applying weak continuous direct current to the scalp, effectively improves the attention and concentration of ADHD children, and improves the impulse disorder of patients, but related research is still in its infancy. Based on a review of a large number of existing literatures and an analysis of the pathogenesis and principle of ADHD, this paper summarized the research on tDCS in the treatment of ADHD in recent years from the aspects of treatment mechanism, safety and stimulation parameters, and simply compared the application of tDCS with other non-traumatic neuromodulation techniques in the treatment of ADHD. The future development direction of this technology is further discussed.

Long-term effect of non-invasive brain stimulation on hemispatial neglect, functional outcomes, and mortality after stroke: ELETRON trial extend

INTRODUCTION

Our primary clinical trial indicated that anodal stimulation of the right posterior parietal region associated with specific and perceptual task training was superior to placebo in reducing stroke-induced hemispatial neglect (HN) immediately after the treatment protocol. However, our primary study did not investigate whether this benefit was maintained in the long term after stroke. Therefore, this study aimed to evaluate the long-term effects of the protocol applied in the ELETRON trial on outcomes associated with HN, functionality, and mortality.

METHODS

This was a pilot, multicenter, prospective, randomized, double-blind trial in patients with HN after stroke who underwent either active tDCS (anodal tDCS or C-tDCS) or sham tDCS in addition to specific and perceptual task training. The outcomes were evaluated on the last day of the session and after 1 year of stimulation (follow-up). Daily evolution rates were calculated as the difference between the values observed between the moments divided by the follow-up time for each individual. The primary outcome was the rate of HN evolution according to the BIT-C scale. The secondary outcome was CBS evolution rate. The exploratory outcomes were the evolution rate of functional disability and autonomy assessed by FIM and BI, quality of life assessed by EQ 5D, stroke severity using the NIHSS, and functional dependence assessed by mRS. Death was examined separately. A linear regression model with a time-adjusted identity link function was used to explain the evolution rates of each outcome of A-tDCS and C-tDCS as a function of sham tDCS. Survival models were adjusted to compare mortality groups.

RESULTS

The evolution rate of BIT-C was not different between A-tDCS (B = 3.18; CI: -4.84-11.19; p = 0.438) and C-tDCS (B = -0.95; CI: -8.97-7.07; p = 0.816) with sham. The secondary and exploratory outcomes showed the same pattern. In addition, there were no statistically significant differences in mortality over time between A-tDCS and S-tDCS (B = 0.322; 95 % CI 0.284-6.707; p = 0.689) and between C-tDCS and S-tDCS (B = -0.798; 95 % CI 0.063-3.195; p = 0.425).

CONCLUSION

The benefits of A-tDCS and C-tDCS were maintained for all long-term post-stroke outcomes.

TRIAL REGISTRATION

RBR-78jvzx - Brazilian Registry of Clinical Trials (Rebec), registered on March 13, 2016.

Transcranial direct current stimulation alleviates the pain severity in people suffering from knee osteoarthritis: a systematic review and meta-analysis

Considerable research has shown the benefits of transcranial direct current stimulation (tDCS) for the alleviation of pain associated with knee osteoarthritis (KOA). Still, a large variance in study protocols and observations across publications exists. We here thus completed a systematic review and meta-analysis to comprehensively and quantitatively characterize the effects of tDCS on KOA-related pain. A search strategy based on the Population, Intervention, Comparison, Outcome, and Study design (PICOS) principle was used to obtain the publications in 7 databases. Studies exploring the effects of tDCS on KOA-related pain were screened, and eligible studies were included. Ten studies of 518 participants using Visual Analogue Scale or Numeric Rating Scale to assess pain were included in the systematic review, and 9 of them were included in meta-analysis. The quality of these studies was good. Compared to control, tDCS induced significant short-term improvements in KOA-related pain with medium heterogeneity (standardized mean difference [SMD] = -0.91, 95% confidence interval [-1.24, -0.58], P < 0.001, I2 = 61%). Subgroup analyses showed that both home-based (SMD = -1.32, 95% CI [-1.65, -0.99], P < 0.001, I 2 = 0%) and laboratory-based intervention (SMD = -0.66, 95% CI [-0.99, -0.33], P < 0.001, I 2 = 40%) with at least 5 sessions per week (SMD = -1.02, 95% CI [-1.41, -0.64], P < 0.001, I 2 = 65%) and/or with a total number of at least 10 sessions (SMD = -1.12, 95% CI [-1.51, -0.74], P < 0.001, I 2 = 59%) can induce maximum benefits for the alleviation of KOA-related pain. The results here showed that tDCS is of great promise to alleviate KOA-related pain. Still, future studies with more rigorous design are needed to confirm the observations from this work, which can ultimately help the determination of appropriate intervention protocol that can maximize such benefits.

Evidence-Based Umbrella Review of Non-Invasive Neuromodulation in Chronic Neuropathic Pain

BACKGROUND AND OBJECTIVE

Non-invasive neuromodulation techniques (NIN), such as transcranial Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS), have been extensively researched for their potential to alleviate pain by reversing neuroplastic changes associated with neuropathic pain (NP), a prevalent and complex condition. However, treating NP remains challenging due to the numerous variables involved, such as different techniques, dosages and aetiologies. It is necessary to provide insights for clinicians and public healthcare managers to support clinical decision-making. This umbrella review aims to consolidate existing evidence on the effectiveness of various NIN in managing chronic NP.

DATABASES AND DATA TREATMENT

A systematic search was conducted in the PubMed/MEDLINE database, including meta-analyses of controlled trials comparing NIN techniques with sham interventions for NP treatment. The quality of included studies was assessed using the AMSTAR-2 tool and the GRADE system, with effect sizes adjusted to the standard mean difference (SMD).

RESULTS

The review included 22 meta-analyses comprising 8151 participants from 214 controlled trials. The most investigated NIN techniques were tDCS and rTMS, with primary targets being the motor cortex and dorsolateral prefrontal cortex. The findings suggest that excitatory protocols, particularly high-frequency rTMS and anodal tDCS, are effective in reducing pain intensity in individuals with NP. However, the overall quality of evidence was rated low, primarily due to heterogeneity among studies and small sample sizes.

CONCLUSION

NIN techniques show promise in managing NP, with potential benefits in pain reduction. However, further high-quality research is needed to establish optimal protocols and long-term effects.

SIGNIFICANCE STATEMENT

This paper consolidates the evidence regarding non-invasive neuromodulation for the treatment of neuropathic pain, including differentiating the most effective techniques based on the aetiology of pain, and provides clinicians with easy access to this critical information. It also highlights key aspects that require further research in the field of non-invasive neuromodulation and neuropathic pain.

Transcranial direct current stimulation (tDCS) enhances cognitive function in schizophrenia: A randomized double-blind sham-controlled trial

This study aimed to examine the cognitive effects of tDCS and the subjective cognitive improvement perceived by patients with schizophrenia. A total of 173 outpatients diagnosed with schizophrenia were recruited for this double-blind, randomized, placebo-controlled trial. Two different stimulation modes were applied: 2 mA 20 minutes active tDCS and sham tDCS. Ten daily sessions over 10 consecutive weekdays were applied, using a bifrontal montage (F3/F4). The Positive and Negative Syndrome Scale for Schizophrenia and the MATRICS Consensus Cognitive Battery (MCCB) were administered at baseline. The MCCB and a scale designed for measuring subjective cognitive improvement were administered to evaluate the outcomes. Post hoc comparisons revealed significant effects between the two types of interventions in Working Memory (EMM difference = 2.716, p < .001) and Neurocognition (EMM difference = 1.289, p = .007. Chi-squared tests demonstrated a significant association between subjective improvement and the treatment group, χ² (2) = 10.413, p = .005, Cramer's V = 0.295. A higher proportion of patients in active tDCS (68.6%) reported cognitive improvement compared to sham tDCS (31.4%). We concluded that tDCS can enhance cognition and generate a satisfactory perception of cognitive improvement in patients with schizophrenia.

The Interplay Between Sleep Apnea and Postpartum Depression

The complicated association between sleep apnea and postpartum depression (PPD), two diseases that can have a major influence on a mother's health and well-being, is examined in this thorough review. An increasing number of people are realizing that sleep apnea, which is defined by repeated bouts of upper airway obstruction during sleep, may be a risk factor for PPD. The literature currently available on the frequency, common risk factors, and possible processes relating these two disorders is summarized in this study. We investigate the potential roles that sleep apnea-related hormone fluctuations, intermittent hypoxia, and fragmented sleep may play in the onset or aggravation of PPD. We also talk about the difficulties in identifying sleep apnea in the postpartum phase and how it can affect childcare and mother-infant attachment. The evaluation assesses the effectiveness of existing screening techniques, available treatments, and how well they manage both illnesses at the same time. Lastly, we identify research gaps and suggest future lines of inquiry to enhance maternal health outcomes.

Enhanced computerized cognitive remediation therapy improved cognitive function, negative symptoms, and GDNF in male long-term inpatients with schizophrenia

Objective

Negative and cognitive symptoms present significant challenges in patients with schizophrenia, and cognitive remediation is a promising approach to alleviate these symptoms. This study aimed to explore the efficacy of computerized cognitive remediation therapy (CCRT) on psychiatric symptoms, cognitive deficits, and serum levels of brain-derived neurotrophic factor (BDNF) and glial cell line-derived neurotrophic factor (GDNF) in patients with schizophrenia.

Materials and methods

Forty male long-term institutionalized inpatients with schizophrenia were assigned to either a CCRT group (n = 20) or a control group (n = 20). The CCRT intervention consisted of 40 individual 40-min sessions over 8 weeks, conducted five times a week. Psychiatric symptoms, cognition, and serum levels of BDNF and GDNF were assessed at baseline, 4 weeks, and 8 weeks.

Results

Compared to the control group, the CCRT group exhibited decreased total Positive and Negative Syndrome Scale and negative subscale scores, as well as increased Montreal Cognitive Assessment and Repeatable Battery for the Assessment of Neuropsychological Status scores. Moreover, improvements in list recall were associated with reduced negative symptoms. Additionally, CCRT ameliorated the decrease in serum GDNF levels in patients with schizophrenia.

Conclusion

The effectiveness of CCRT in alleviating negative symptoms was associated with improvements in list recall, and GDNF may play a role in the observed effects of CCRT in patients with schizophrenia.

Advancing Neuroscience and Therapy: Insights into Genetic and Non-Genetic Neuromodulation Approaches

Neuromodulation stands as a cutting-edge approach in the fields of neuroscience and therapeutic intervention typically involving the regulation of neural activity through physical and chemical stimuli. The purpose of this review is to provide an overview and evaluation of different neuromodulation techniques, anticipating a clearer understanding of the future developmental trajectories and the challenges faced within the domain of neuromodulation that can be achieved. This review categorizes neuromodulation techniques into genetic neuromodulation methods (including optogenetics, chemogenetics, sonogenetics, and magnetogenetics) and non-genetic neuromodulation methods (including deep brain stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, transcranial ultrasound stimulation, photobiomodulation therapy, infrared neuromodulation, electromagnetic stimulation, sensory stimulation therapy, and multi-physical-factor stimulation techniques). By systematically evaluating the principles, mechanisms, advantages, limitations, and efficacy in modulating neuronal activity and the potential applications in interventions of neurological disorders of these neuromodulation techniques, a comprehensive picture is gradually emerging regarding the advantages and challenges of neuromodulation techniques, their developmental trajectory, and their potential clinical applications. This review highlights significant advancements in applying these techniques to treat neurological and psychiatric disorders. Genetic methods, such as sonogenetics and magnetogenetics, have demonstrated high specificity and temporal precision in targeting neuronal populations, while non-genetic methods, such as transcranial magnetic stimulation and photobiomodulation therapy, offer noninvasive and versatile clinical intervention options. The transformative potential of these neuromodulation techniques in neuroscience research and clinical practice is underscored, emphasizing the need for integration and innovation in technologies, the optimization of delivery methods, the improvement of mediums, and the evaluation of toxicity to fully harness their therapeutic potential.

Neuromodulatory effect of transcranial direct current stimulation on cue reactivity and craving in young adults with internet gaming disorder: an event-related potential study

Objective

This study assessed the effects of transcranial direct current stimulation (tDCS) on cue reactivity and craving for game-related cues using event-related potentials (ERPs) in internet gaming disorder (IGD) patients.

Methods

At baseline, a series of game-related and neutral pictures were shown to both IGD and healthy controls (HCs) while ERPs were recorded. Late positive potentials (LPP) were used to investigate cue reactivity. During intervention, IGD patients received 10 sessions (two sessions/day for 5 consecutive days, 2 mA for 20 min/session) of tDCS to the left (anode stimulation) and right (cathode) dorsolateral prefrontal cortex. Subjectively assessed craving and LPP component was analyzed before stimulation and at the 1-month follow-up after tDCS in IGD.

Results

At baseline, patients with IGD showed higher LPP amplitudes for game-related cues in the centro-parietal and parietal regions than HCs. After 10 sessions of tDCS, increased LPP amplitudes decreased significantly at 1-month follow-up., as well as subjective craving for gaming.

Conclusion

These findings suggest that neurophysiological arousal in response to game-related cues in the IGD group could be modulated by the effects of tDCS. LPP was a significant neurophysiological marker of the neuroplastic response of cue reactivity underlying the therapeutic effect of tDCS on IGD. Based on the present findings, tDCS could be expanded to the treatment of other addictive disorders, including substance use disorder and behavioral addictions.

Important role of the right hemisphere in post-stroke cognitive impairment: a functional near-infrared spectroscopy study

Significance

The current neuromodulation treatment for post-stroke cognitive impairment (PSCI) is formulated based on interhemispheric inhibition, which is particularly relevant in the context of motor disorders after stroke. However, the pathological mechanism of PSCI remains unclear, which is completely different from motor disorders. Therefore, exploring the pathological brain characteristics of PSCI can provide a reliable theoretical basis for effective neuromodulation treatment for it.

Aim

We explored different functional connectivity (FC) manifestations of PSCI with or without aphasia via functional near-infrared spectroscopy (fNIRS) to provide a pathological basis for the neuromodulation strategy.

Approach

We collected cognitive performance and fNIRS data from patients with PSCI without aphasia (PSCI group, n = 33 ) and patients with post-stroke aphasia (PSA group, n = 31 ), using normal cognition stroke patients (SC group, n = 32 ) and healthy subjects (HC group, n = 31 ) as controls. Differences in FC among different types of stroke-related cognitive impairment were analyzed.

Results

The overall FC in the PSCI group was lower than that in the SC or HC group, and the FCs of the right hemisphere, the right default mode network (DMN), and the right central executive network (CEN) of PSCI patients were significantly lower than those of the left ones. In the PSA group, the FCs of the DMN and CEN were not lower than those in the SC and HC groups, and the FC of the left hemisphere was significantly greater than that of the right hemisphere. In addition, the FC of PSCI patients with right lesions was weaker than that of left lesions, which was closely correlated with the cognitive scale.

Conclusions

Unlike the left hemisphere activation strategy commonly used previously, our results suggest that the important role of the right hemisphere may be overlooked in PSCI patients with or without aphasia. Future treatment options and studies could consider focusing on the right hemisphere or bilateral hemispheres.

Transcranial Direct Current Stimulation for Global Cognition in Mild Cognitive Impairment

Mild cognitive impairment (MCI) is a condition characterized by noticeable deficits in memory retrieval or other cognitive domains than the individuals with the same age but do not significantly interfere with daily functioning. It represents an intermediate stage between normal aging and dementia, and a crucial opportunity for intervention prior to extensive cognitive decline. Transcranial direct current stimulation (tDCS), a non-invasive neuromodulation technique, has shown promise in enhancing global cognition in MCI. Current evidence suggests that tDCS provides short-term cognitive benefits, particularly in memory and attention, with moderate effects observed in processing speed. However, its impact on executive function and language remains inconsistent, highlighting variability in individual responses and study methodologies. While long-term efficacy remains uncertain due to limited longitudinal research and short follow-up periods, safety concerns, especially with self-administered tDCS such as in home-based tDCS, underscore the need for proper training and device innovation. Despite this, tDCS is a promising, portable tool for cognitive enhancement in MCI, with potential to delay progression to dementia. Addressing challenges such as optimizing stimulation protocols, accounting for individual neuroanatomical variability, and establishing long-term effectiveness will be essential for its broader clinical adoption. Future research should focus on standardizing methodologies, incorporating biomarkers to predict treatment response, and conducting large-scale, longitudinal studies to refine its therapeutic application.

Perceptual and Cognitive Effects of Focal Transcranial Direct Current Stimulation of Auditory Cortex in Tinnitus

OBJECTIVES

Transcranial direct current stimulation (tDCS) has been studied as a potential treatment for many brain conditions. Although tDCS is well tolerated, continued study of perceptual and cognitive side effects is warranted, given the complexity of functional brain organization. This study tests the feasibility of brief tablet-based tasks to assess auditory and cognitive side effects in a recently reported pilot study of auditory-cortex tDCS in chronic tinnitus and attempts to confirm that this untested multisession tDCS protocol does not worsen hearing.

MATERIALS AND METHODS

Participants with chronic tinnitus completed two hearing tasks (pure-tone thresholds, Words In Noise [WIN]) and two cognitive tasks (Flanker, Dimension Change Card Sort) from the NIH Toolbox (2024 Toolbox Assessments, Inc, Lincolnwood, IL). Participants were randomized to active or sham 4×1 silver/silver-chloride tDCS of left auditory cortex (n = 10/group). Tasks were completed immediately before and after the first tDCS session, and after the fifth/final tDCS session. Statistics included linear mixed-effects models for change in task performance over time.

RESULTS

Before tDCS, performance on both auditory tasks was highly correlated with clinical audiometry, supporting the external validity of these measures (r2 > 0.89 for all). Although overall auditory task performance did not change after active or sham tDCS, detection of right-ear WIN stimuli modestly improved after five active tDCS sessions (t34 = -2.07, p = 0.05). On cognitive tasks, reaction times (RTs) were quicker after sham tDCS, reflecting expected practice effects (eg, t88 = 3.22, p = 0.002 after five sessions on the Flanker task). However, RTs did not improve over repeated sessions in the active group, suggesting that tDCS interfered with learning these practice effects.

CONCLUSIONS

Repeated sessions of auditory-cortex tDCS do not seem to adversely affect hearing or cognition but may modestly improve hearing in noise and interfere with some types of motor learning. Low-burden cognitive/perceptual test batteries could be a powerful way to identify adverse effects and new treatment targets in brain stimulation research.

Effects of Transcranial and Trans-Spinal Direct Current Stimulation Combined with Robot-Assisted Gait Training on Gait and Fatigue in Patients with Multiple Sclerosis: A Double-Blind, Randomized, Sham-Controlled Study

Background/Objectives: Multiple Sclerosis (MS) is a chronic neurological condition that impairs motor and sensory functions, particularly gait. Non-invasive neuromodulation techniques aim to enhance functional recovery and motor-cognitive outcomes, though their effectiveness remains debated. This study compared the effects of transcranial direct current stimulation (tDCS) and trans-spinal direct current stimulation (tsDCS), combined with robotic-assisted gait training (RAGT), on motor function and fatigue in people with MS (pwMS). Methods: This double-blind, randomized, sham-controlled clinical trial included 35 pwMS, who participated in 12 sessions of 20 min anodal tDCS (n = 11), cathodal tsDCS (n = 12), or sham treatment (n = 12), in addition to RAGT. Primary outcomes were assessed using the Timed 25-foot Walk (T25-FW), Timed Up and Go (TUG), walking speed, and Multiple Sclerosis Walking Scale-12 (MSWS-12). Fatigue was assessed with the Fatigue Severity Scale (FSS) and the Fatigue Impact Scale (FIS). ClinicalTrials number: NCT06121635. Results: Significant improvements in gait speed, T25-FW, MSWS-12, TUG scores, and fatigue (FSS) favored tDCS and tsDCS over sham stimulation. While no differences were found between tDCS and tsDCS, the tsDCS group showed a significant improvement in the FIS physical subscale compared to sham, unlike the tDCS group. Conclusions: tDCS and tsDCS, combined with RAGT, improve walking and reduce fatigue in pwMS, highlighting their potential in motor rehabilitation.

Optimal Brain Targets for Enhancing Vocal Performance With Transcranial Direct Current Stimulation

Transcranial direct current stimulation (tDCS) can be used to temporarily and reversibly modulate brain functions and is an increasingly utilized tool to investigate the relationships between brain and behavior. This study aimed to identify the brain area where tDCS has the greatest effect on vocal quality, vocal range, neuromotor functioning of the larynx, and self-reported vocal effort in vocally healthy individuals. Sixteen adults, non-singers, with a mean age of 22.5 (±1.9) years and no vocal symptoms or brain dysfunction, participated in this double-blinded randomized crossover clinical trial. The participants underwent four anodal tDCS session (20 minutes; 2 mA) in targeting different areas-cerebellum, primary motor cortex (M1), primary somatosensory cortex (S1), and dorsolateral prefrontal cortex (DLPFC)-with a 7-day washout period between sessions. Volunteers were evaluated for vocal performance before and after each tDCS session. Voice recordings were taken to assess the following vocal parameters: vocal range profile (VRP) at weak and strong intensities; vocal quality (jitter, shimmer, irregularity, glottal-to-noise excitation ratio, and dysphonia acoustic index) at weak, habitual, and strong intensities; laryngeal diadochokinesis, and self-reported vocal effort using the adapted Borg CR10 scale. M1 stimulation enhanced the VRP by increasing maximum intensity and improving vocal quality, particularly at habitual and strong intensities. Similarly, S1 stimulation improved vocal quality at strong intensities but reduced the VRP by lowering the maximum fundamental frequency. Cerebellum stimulation enhanced neuromuscular control and coordination of the larynx without affecting vocal quality. Additionally, self-reported vocal effort decreased across all stimulated areas following tDCS. Our findings indicate that tDCS applied to different brain areas produces varying effects on vocal parameters.

The use of combined cognitive training and non-invasive brain stimulation to modulate impulsivity in adult populations: a systematic review and meta-analysis of existing studies

Introduction

Impulsivity, a tendency to act rashly and without forethought, is a core feature of many mental disorders that has been implicated in suicidality and offending behaviours. While research supports the use of non-invasive brain stimulation (NIBS) techniques, such as transcranial direct current stimulation (tDCS), to modulate brain functions, no studies specifically reviewed the use of combined cognitive training and NIBS to modulate impulsivity.

Methods

We aimed to conduct a systematic review and meta-analysis to synthesise the literature on the use of combined cognitive training and NIBS to modulate impulsivity and its subdomains (motor, delay discounting, reflection). We searched Scopus, PsychInfo, Medline, and Cinahl electronic databases, dissertations database, and Google scholar up to September 2024.

Results

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, four randomised controlled studies involving the use of combined cognitive training and tDCS in 127 subjects were included in the study. These studies included subjects with substance use disorders, obesity, and Parkinson's disease. Meta-analysis showed that combined cognitive training and tDCS had no statistically significant effects on motor impulsivity as measured using reaction times on the Stop Signal Task and Go/No Go tasks. One study that measured impulsiveness scores on a delay discounting task also showed no significant results. No studies measured reflection or cognitive impulsivity.

Discussion

There is a dearth of literature on the use of combined cognitive training and NIBS for impulsivity. This in conjunction of clinical heterogeneity across studies makes it difficult to draw definitive conclusions about the neuromodulation of impulsivity and its subdomains using combined cognitive training and NIBS. The findings of this study highlight the need to conduct more studies in the field.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD 42024511576.

Progress in the mechanisms of pain associated with neurodegenerative diseases

Neurodegenerative diseases (NDDs) represent a class of neurological disorders characterized by the progressive degeneration or loss of neurons, impacting millions of individuals globally. In addition to the typical manifestations, pain is a prevalent symptom associated with NDDs, seriously impacting the quality of life for patients. The pathogenesis of pain associated with NDDs is intricate and multifaceted. Currently, the clinical management of NDDs-related pain symptoms predominantly relies on conventional pharmacological agents or physical therapy. However, these approaches often fail to produce satisfactory outcomes. This article summarizes the underlying mechanisms of major NDDs-associated pain: Neuroinflammation, Brain and spinal cord dysfunctions, Mitochondrial dysfunction, Risk gene and pathological protein, as well as Receptor, channel, and neurotransmitter. While numerous studies have investigated the downstream pathological processes associated with these mechanisms, there remains a significant gap in identifying the key initiating factors. Specifically, there is insufficient evidence for the upstream elements that activate microglia and astrocytes in neuroinflammation leading to pain in NDDs. Likewise, there is an absence of upstream factors elucidating how dysfunctions in the brain and spinal cord, as well as mitochondrial impairments, contribute to the development of pain. Furthermore, the specific mechanisms through which hallmark pathological proteins related to NDDs contribute to these pathological processes remain inadequately understood. The objective of this article is to synthesize the existing mechanisms underlying pain associated with NDDs, including Alzheimer's disease, Parkinson's disease, Huntington's disease, Schizophrenia, Amyotrophic lateral sclerosis, and Multiple sclerosis, while also identifying gaps and deficiencies in these mechanisms. This paper offers insights for future research trajectories. Given the intricate pathogenesis of NDDs-related pain, it emphasizes that a promising short-term strategy is combination therapy-intervening concurrently in multiple pathological processes-akin to the cocktail approach utilized in treating acquired immunodeficiency syndrome (AIDS). For long-term advancements, achieving breakthroughs in the treatment of the NDDs themselves will remain essential for alleviating accompanying pain symptoms.

Effects of osteopathic manipulative treatment associated with transcranial direct current stimulation in individuals with chronic low back pain: A double-blind, randomised placebo-controlled trial

OBJECTIVE

To evaluate the effectiveness of osteopathic manipulative treatment (OMT) associated with transcranial direct current stimulation (tDCS) in reducing pain, disability, and improving quality of life in participants with non-specific chronic low back pain.

DESIGN

A randomised double-blind clinical trial.

SETTING

Clinical outpatient unit.

SUBJECTS

72 participants with non-specific chronic low back pain were randomised into three groups: active tDCS + OMT (n = 24), sham tDCS + sham OMT (n = 24), and sham tDCS + OMT (n = 24).

INTERVENTIONS

Evaluations were performed before, after the intervention, and one month post-intervention. tDCS consisted of ten 20-minute sessions over two weeks (five sessions per week). OMT was administered once per week, with two sessions conducted before the first and sixth tDCS sessions.

MAIN MEASURES

Pain, disability, and quality of life were assessed at baseline, after two weeks, and at one month of follow-up.

RESULTS

The visual analogue scale showed a significant decrease in all groups (p < 0.001). However, tDCS + OMT and sham tDCS + OMT demonstrated a clinically significant reduction compared to the sham combination (effect size n² = 0.315). Roland-Morris scores decreased across all groups without specific group effects. EuroQoL 5-Dimension 3-Level improvement was observed only in the tDCS + OMT and sham tDCS + OMT groups (significant difference between T2 and T0, p = 0.002).

CONCLUSION

The combination of OMT and tDCS did not provide clinically significant improvement over OMT alone in participants with non-specific chronic low back pain.

Effects of transcranial direct current stimulation (tDCS) associated with balance training in individuals with Parkinson's: Study protocol for a randomized clinical trial

The present study aimed to investigate the effects of balance training associated with cerebellar tDCS on postural control in individuals with PD. This is a randomized clinical trial in which individuals were allocated to an experimental group (EG) or placebo group (PG), in which a conventional protocol of 10 Physiotherapy sessions for locomotor training and postural control was applied. In the EG, tDCS was applied, with a current setting of 1.5 mA for 20 min simultaneously with postural control training. In the PG, tDCS was applied in sham mode, with the same electrode positioning and the same number of sessions as the EG. The sample compared 34 individuals with PD (EG: 17; PG: 17).Cerebellar tDCS associated with balance training may help improve postural control and balance in walkers with Parkinson's Disease. The hypothesis is, if walking improve, the benefits may be accompanied by better balance and reduced fear of falling, and individuals may experience greater free-living physical activity at home and in the community.

Examining the effectiveness of motor imagery combined with non-invasive brain stimulation for upper limb recovery in stroke patients: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) are common non-invasive brain stimulation (NIBS) methods for functional recovery after stroke. Motor imagery (MI) can be used in the rehabilitation of limb motor function after stroke, but its effectiveness remains to be rigorously established. Furthermore, there is a growing interest in the combined application of NIBS with MI, yet the evidence regarding its impact on the recovery of upper limb function after stroke is inconclusive. This meta-analysis aimed to demonstrate whether combining the two is superior to NIBS alone or MI alone to provide a reference for clinical decision-making.

METHODS

PubMed, EMBASE, Cochrane Library, Web of Science, Science Direct, CNKI, WANFANG, and VIP databases were searched for randomized controlled trials on the effects of MI combined NIBS in motor function recovery after stroke until February 2024. The outcomes of interest were associated with body functions or structure (impairment) and activity (functional). The primary outcome was assessed with the Fugl-Meyer assessment of the upper extremity (FMA-UE) for motor function of the upper limbs and the modified Barthel Index (MBI) for the ability to perform daily living activities. For secondary outcomes, functional activity level was measured using wolf motor function test (WMFT) and action research arm test (ARAT), and cortical excitability was assessed using cortical latency of motor evoked potential (MEP-CL) and central motor conduction time (CMCT). The methodological quality of the selected studies was evaluated using the evidence‑based Cochrane Collaboration's tool. A meta-analysis was performed to calculate the mean differences (MD) or the standard mean differences (SMD) and 95% confidence intervals (CI) with random-effect models.

RESULTS

A total of 14 articles, including 886 patients, were reviewed in the meta-analysis. In comparison with MI or NIBS alone, the combined therapy significantly improved the motor function of the upper limbs (MD = 5.43; 95% CI 4.34-6.53; P < 0.00001) and the ability to perform activities of daily living (MD = 11.07; 95% CI 6.33-15.80; P < 0.00001). Subgroup analyses showed an interaction between the stage of stroke, the type of MI, and the type of NIBS with the effect of the combination therapy.

CONCLUSION

The combination of MI and NIBS may be a promising therapeutic approach to enhance upper limb motor function, functional activity, and activities of daily living after stroke.

SYSTEMATIC REGISTRATION

PROSPERO registration CRD42023493073.

Shaping tomorrow: how the STEP training course pioneered noninvasive brain stimulation training for psychiatry in France

Over the past three decades, non-invasive brain stimulation (NIBS) techniques have gained worldwide attention and demonstrated therapeutic potential in various medical fields, particularly psychiatry. The emergence of these novel techniques has led to an increased need for robust training programs to provide practitioners, whether clinicians or scientists, with the necessary skills and knowledge. In response, a comprehensive training curriculum for NIBS in psychiatry has been developed in France. This curriculum was developed by a group of researchers and psychiatrists interested in the clinical application of NIBS in psychiatry, called STEP - Stimulation Transcranienne en Psychiatrie, under the auspices of the French Association of Biological Psychiatry. This perspective outlines the development and implementation of this course, tracing its inception, the evolution of the program, and the challenges encountered along the way. The position of the course in the national and international environment and its future prospects are also discussed. Through this perspective, we aim to summarize the collaborative efforts to promote NIBS teaching and research in French psychiatry.

Stakeholder perspectives on non-invasive brain stimulation

Non-invasive brain stimulation (NIBS) techniques such as transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS) have made great progress in recent years and offer boundless potential for the neuroscientific research and treatment of disorders. However, the possible use of NIBS devices for neuro-doping and neuroenhancement in healthy individuals and the military are poorly regulated. The great potentials and diverse applications can have an impact on the future development of the technology and society. This participatory study therefore aims to summarize the perspectives of different stakeholder groups with the help of qualitative workshops. Nine qualitative on-site and virtual workshops were conducted in the study with 91 individuals from seven stakeholder groups: patients, students, do-it-yourself home users of tDCS, clinical practitioners, industry representatives, philosophers, and policy experts. The co-creative and design-based workshops were tailored to each group to document the wishes, fears, and general comments of the participants. The outlooks from each group were collected in written form and summarized into different categories. The result is a comprehensive overview of the different aspects that need to be considered in the field of NIBS. For example, several groups expressed the wish for home-based tDCS under medical supervision as a potential therapeutic intervention and discussed the associated technical specifications. Other topics that were addressed were performance enhancement for certain professional groups, training requirements for practitioners, and questions of agency, among others. This qualitative participatory research highlights the potential of tDCS and repetitive TMS as alternative therapies to medication, with fewer adverse effects and home-based use for tDCS. The ethical and societal impact of the abuse of NIBS for non-clinical use must be considered for policy-making and regulation implementations. This study adds to the neuroethical debate on the responsible use and application of NIBS technologies, taking into consideration the different perspectives of important stakeholders in the field.