Timing-dependent synergies between noninvasive motor cortex and spinal cord stimulation in chronic cervical spinal cord injury

Precise movement requires integrating descending motor control with sensory feedback. Sensory networks interact strongly with descending motor circuits within the spinal cord. We targeted this interaction by pairing stimulation of the motor cortex with coordinated stimulation of the cervical spinal cord. We used separate non-invasive and epidural experiments to test the hypothesis that the strongest muscle response would occur when paired brain and spinal cord stimuli simultaneously converge within the spinal cord. For non-invasive experiments, we measured arm and hand muscle motor evoked potentials (MEPs) in response to transcranial magnetic stimulation (TMS) and transcutaneous spinal cord stimulation (TSCS) in 16 individuals with chronic spinal cord injury (SCI) and 15 uninjured individuals. We compared this noninvasive approach to intraoperative paired stimulation experiments using dorsal epidural electrodes in 38 individuals undergoing surgery for cervical myelopathy. We observed augmented muscle responses to suprathreshold TMS when subthreshold TSCS stimuli were timed to converge synchronously in the spinal cord. At convergent timing, target muscle MEPs increased by 11.0% overall (13.3% in people with SCI, 6.2% in uninjured individuals) compared to non-convergent time intervals. Facilitation correlated with TSCS intensity, with intensity close to movement threshold being most effective. Facilitation did not correlate with SCI level or severity, indicating spared circuits were sufficient for this effect. Noninvasive pairing produced less facilitation compared to intraoperative (epidural) pairing. Thus, sensorimotor interactions in the cervical spinal spinal cord can be targeted with paired stimulation in health and after SCI.

Highlights

Electrical stimulation of spinal sensory circuits can augment cortical motor evoked potentials, but only when they are timed to arrive synchronously in the spinal cord.Facilitation was at least as large in people with spinal cord injury compared with uninjured controls, suggesting that the necessary circuits for this facilitation were spared by injury.The magnitude of facilitation with noninvasive facilitation was smaller than the facilitation effect observed with epidural stimulation during elective spinal surgery, but they both rely on precisely timed interactions.Facilitation of hand and arm muscle responses correlated with the transcutaneous spinal stimulation intensity, suggesting that the magnitude of the pairing effect can be improved.Pairing was effective both in uninjured participants and those with SCI, independently of injury level, severity, or chronicity.

Robotic transcranial magnetic stimulation in the treatment of depression: a pilot study

There has been an increasing demand for robotic coil positioning during repetitive transcranial magnetic stimulation (rTMS) treatment. Accurate coil positioning is crucial because rTMS generally targets specific brain regions for both research and clinical application with other reasons such as safety, consistency and reliability and individual variablity. Some previous studies have employed industrial robots or co-robots and showed they can more precisely stimulate the target cortical regions than traditional manual methods. In this study, we not only developed a custom-TMS robot for better TMS coil placement but also analyzed the therapeutic effects on depression. Treatment effects were evaluated by measuring regional cerebral blood flow (rCBF) using single-photon emission computed tomography and depression severity before and after rTMS for the two positioning methods. The rTMS preparation time with our robotic coil placement was reduced by 53% compared with that of the manual method. The position and orientation errors were also significantly reduced from 11.17 mm and 4.06° to 0.94 mm and 0.11°, respectively, confirming the superiority of robotic positioning. The results from clinical and neuroimaging assessments indicated comparable improvements in depression severity and rCBF in the left dorsolateral prefrontal cortex between the robotic and manual rTMS groups. A questionnaire was used to determine the patients' feelings about the robotic system, including the safety and preparation time. A high safety score indicated good acceptability of robotic rTMS at the clinical site.

3D-printed helmet-type neuro-navigation approach (I-Helmet) for transcranial magnetic stimulation

Neuro-navigation is a key technology to ensure the clinical efficacy of TMS. However, the neuro-navigation system based on positioning sensor is currently unable to be promoted and applied in clinical practice due to its time-consuming and high-cost. In the present study, we designed I-Helmet system to promote an individualized and clinically friendly neuro-navigation approach to TMS clinical application. I-Helmet system is based on C++ with a graphical user interface that allows users to design a 3D-printed helmet model for coil navigation. Besides, a dedicated coil positioning accuracy detection method was promoted based on three-dimensional (3D) printing and 3D laser scanning for evaluation. T1 images were collected from 24 subjects, and based on each image, phantom were created to simulate skin and hair. Six 3D-printed helmets with the head positioning hole enlarged by 0-5% tolerance in 1% increments were designed to evaluate the influences of skin, hair, and helmet-tolerance on the positioning accuracy and contact force of I-Helmet. Finally, I-Helmet system was evaluated by comparing its positioning accuracy with three skin hardnesses, three hair styles, three operators, and with or without landmarks. The accuracy of the proposed coil positioning accuracy detection method was about 0.30 mm in position and 0.22° in orientation. Skin and hair had significant influences on positioning accuracy (p < 0.0001), whereas different skin hardnesses, hair styles, and operators did not (p > 0.05). The tolerance of the helmet presented significant influences on positioning accuracy (p < 0.0001) and contact force (p < 0.0001). The positioning accuracy significantly increased (p < 0.0001) with landmark guided I-Helmet. 3D-printed helmet-type Neuro-navigation approach (I-Helmet) with 3% tolerance and landmarks met the positioning requirements for TMS in clinical practice with less than 5 N mean contact force, 3-5 mm positioning accuracy, 65.7 s mean operation time, and 50-yuan material cost. All the results suggest that the cost of I-Helmet system may be much less than the that of training clinical doctors to position the coil of TMS operation during short period of time.

Non-invasive brain stimulation for osteoarthritis

Osteoarthritis (OA) is a degenerative joint disease, the prevalence of OA is increasing, and the elderly are the most common in patients with OA. OA has a severe impact on the daily life of patients, this increases the demand for treatment of OA. In recent years, the application of non-invasive brain stimulation (NIBS) has attracted extensive attention. It has been confirmed that NIBS plays an important role in regulating cortical excitability and oscillatory rhythm in specific brain regions. In this review, we summarized the therapeutic effects and mechanisms of different NIBS techniques in OA, clarified the potential of NIBS as a treatment choice for OA, and provided prospects for further research in the future.

Devices and Technology in Transcranial Magnetic Stimulation: A Systematic Review

The technology for transcranial magnetic stimulation (TMS) has significantly changed over the years, with important improvements in the signal generators, the coils, the positioning systems, and the software for modeling, optimization, and therapy planning. In this systematic literature review (SLR), the evolution of each component of TMS technology is presented and analyzed to assess the limitations to overcome. This SLR was carried out following the PRISMA 2020 statement. Published articles of TMS were searched for in four databases (Web of Science, PubMed, Scopus, IEEE). Conference papers and other reviews were excluded. Records were filtered using terms about TMS technology with a semi-automatic software; articles that did not present new technology developments were excluded manually. After this screening, 101 records were included, with 19 articles proposing new stimulator designs (18.8%), 46 presenting or adapting coils (45.5%), 18 proposing systems for coil placement (17.8%), and 43 implementing algorithms for coil optimization (42.6%). The articles were blindly classified by the authors to reduce the risk of bias. However, our results could have been influenced by our research interests, which would affect conclusions for applications in psychiatric and neurological diseases. Our analysis indicates that more emphasis should be placed on optimizing the current technology with a special focus on the experimental validation of models. With this review, we expect to establish the base for future TMS technological developments.

Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines

This article is based on a consensus conference, promoted and supported by the International Federation of Clinical Neurophysiology (IFCN), which took place in Siena (Italy) in October 2018. The meeting intended to update the ten-year-old safety guidelines for the application of transcranial magnetic stimulation (TMS) in research and clinical settings (Rossi et al., 2009). Therefore, only emerging and new issues are covered in detail, leaving still valid the 2009 recommendations regarding the description of conventional or patterned TMS protocols, the screening of subjects/patients, the need of neurophysiological monitoring for new protocols, the utilization of reference thresholds of stimulation, the managing of seizures and the list of minor side effects. New issues discussed in detail from the meeting up to April 2020 are safety issues of recently developed stimulation devices and pulse configurations; duties and responsibility of device makers; novel scenarios of TMS applications such as in the neuroimaging context or imaging-guided and robot-guided TMS; TMS interleaved with transcranial electrical stimulation; safety during paired associative stimulation interventions; and risks of using TMS to induce therapeutic seizures (magnetic seizure therapy). An update on the possible induction of seizures, theoretically the most serious risk of TMS, is provided. It has become apparent that such a risk is low, even in patients taking drugs acting on the central nervous system, at least with the use of traditional stimulation parameters and focal coils for which large data sets are available. Finally, new operational guidelines are provided for safety in planning future trials based on traditional and patterned TMS protocols, as well as a summary of the minimal training requirements for operators, and a note on ethics of neuroenhancement.

Planning Framework for Robot-assisted Blood-Brain Barrier Opening with Focused Ultrasound

This article presents a method to plan BloodBrain Barrier (BBB) disruption with Focused Ultrasound, under neuronavigated robotic assistance. Robotic and acoustic constraints are defined to estimate brain target accessibility. The relevance of the proposed framework is illustrated in specific brain target examples.

Accuracy of robotic coil positioning during transcranial magnetic stimulation

OBJECTIVE

Robotic positioning systems for transcranial magnetic stimulation (TMS) promise improved accuracy and stability of coil placement, but there is limited data on their performance. Investigate the usability, accuracy, and limitations of robotic coil placement with a commercial system, ANT Neuro, in a TMS study.

APPROACH

21 subjects underwent a total of 79 TMS sessions corresponding to 160 hours under robotic coil control. Coil position and orientation were monitored concurrently through an additional neuronavigation system.

MAIN RESULTS

Robot setup took on average 14.5 min. The robot achieved low position and orientation error with median 3.54 mm (overall, 1.34 mm without coil-head spacing) and 3.48°. The error increased over time at a rate of 0.4%/minute for both position and orientation.

SIGNIFICANCE

Robotic TMS systems can provide accurate and stable coil position and orientation in long TMS sessions. Lack of pressure feedback and of manual adjustment of all coil degrees of freedom were limitations of this robotic system.

Non-orthogonal one-step calibration method for robotized transcranial magnetic stimulation

BACKGROUND

Robotized transcranial magnetic stimulation (TMS) combines the benefits of neuro-navigation with automation and provides a precision brain stimulation method. Since the coil will normally remain unmounted between different clinical uses, hand/eye calibration and coil calibration are required before each experiment. Today, these two steps are still separate: hand/eye calibration is performed using methods proposed by Tsai/Lenz or Floris Ernst, and then the coil calibration is carried out based on the traditional TMS experimental step. The process is complex and time-consuming, and traditional coil calibration using a handheld probe is susceptible to greater calibration error.

METHODS

A novel one-step calibration method has been developed to confirm hand/eye and coil calibration results by formulating a matrix equation system and estimating its solution. Hand/eye calibration and coil calibration are performed to confirm the pose relationships of the marker/end effector 'X', probe/end effector 'Y', and robot/world 'Z'. First, the coil is fixed on the end effector of the robot. During the one-step calibration process, a marker is mounted on the top of the coil and a calibration probe is fixed at the actual effective position of the coil. Next, the robot end effector is moved to a series of random positions 'A', the tracking data of marker 'B' and probe 'C' is obtained correspondingly. Then, a matrix equation system AX = ZB and AY = ZC can be acquired, and it is computed using a least-squares approach. Finally, the calibration probe is removed after calibration, while the marker remains fixed to the coil during the TMS experiment. The methods were evaluated based on simulation data and on experimental data from an optical tracking device. We compared our methods with two classical methods: the QR24 method proposed by Floris Ernst and the handheld coil calibration method.

RESULTS

The new methods outperform the QR24 method in the aspect of translational accuracy and performs similarly in the aspect of rotational accuracy, the total translational error decreased more than fifty percent. The new approach also outperforms traditional handheld coil calibration of navigated TMS systems, the total translational error decreased three- to fourfold, and the rotational error decreased six- to eightfold. Furthermore, the convergence speed is improved 16- to 27-fold for the new algorithms.

CONCLUSION

These results suggest that the new method can be used for hand/eye and coil calibration of a robotized TMS system. Two complex steps can be simplified using a least-squares approach.

Proposal for an accurate TMS-MRI co-registration process via 3D laser scanning

An important technical issue in transcranial magnetic stimulation (TMS) usage is how accurately the specific brain areas activated by TMS are assessed. However, in practice, electric field induced in TMS is dispersed and therefore actual estimation is still difficult. As a preliminary step, the projection line which is perpendicular to the TMS stimulation coil beneath the center of the coil must be accurately estimated into the brain. Therefore, we have developed a new TMS-MRI co-registration procedure that employs a 3D laser-scanner system that is very useful for general hand-manipulated TMS, and which easily estimates the TMS projection point onto the brain. The proposed system accurately captures the positional relationship between the TMS coil and anatomical images. The results of 3D image processing revealed that the registration error at each stage was kept within the submillimeter level. In addition, a motor evoked potential experiment examining the right finger motor area revealed that understandable responses were obtained when stimulation was targeted to the three different motor areas according to Penfield's map. 3D laser scanning is a technique of substantial recent interest for anatomical co-registration. The proposed method demonstrated submillimeter level accuracy of TMS-MRI co-registration.

High-definition transcranial direct current stimulation induces both acute and persistent changes in broadband cortical synchronization: a simultaneous tDCS-EEG study

The goal of this study was to develop methods for simultaneously acquiring electrophysiological data during high-definition transcranial direct current stimulation (tDCS) using high-resolution electroencephalography (EEG). Previous studies have pointed to the after-effects of tDCS on both motor and cognitive performance, and there appears to be potential for using tDCS in a variety of clinical applications. However, little is known about the real-time effects of tDCS on rhythmic cortical activity in humans due to the technical challenges of simultaneously obtaining electrophysiological data during ongoing stimulation. Furthermore, the mechanisms of action of tDCS in humans are not well understood. We have conducted a simultaneous tDCS-EEG study in a group of healthy human subjects. Significant acute and persistent changes in spontaneous neural activity and event-related synchronization (ERS) were observed during and after the application of high-definition tDCS over the left sensorimotor cortex. Both anodal and cathodal stimulation resulted in acute global changes in broadband cortical activity which were significantly different than the changes observed in response to sham stimulation. For the group of eight subjects studied, broadband individual changes in spontaneous activity during stimulation were apparent both locally and globally. In addition, we found that high-definition tDCS of the left sensorimotor cortex can induce significant ipsilateral and contralateral changes in event-related desynchronization and ERS during motor imagination following the end of the stimulation period. Overall, our results demonstrate the feasibility of acquiring high-resolution EEG during high-definition tDCS and provide evidence that tDCS in humans directly modulates rhythmic cortical synchronization during and after its administration.

A custom robot for Transcranial Magnetic Stimulation: first assessment on healthy subjects

In this paper, a custom robotic system for Transcranial Magnetic Stimulation is assessed in clinical conditions on healthy subjects. A motor cortex mapping is performed using the robotic system with comparison to a manual approach using a neuronavigation system. Stimulation accuracy, repeatability are evaluated as well as the feeling of the system operator and the subject in terms of comfort, tiredness, stress level, ease-of-use. Very encouraging results are obtained on all these aspects, which strengthens the idea of developing robotic assistance for TMS.

Hot Spot Hound: a novel robot-assisted platform for enhancing TMS performance

Transcranial Magnetic Stimulation (TMS) is a non-invasive technique that produces excitatory depolarization in the neurons located in the cerebral cortex. In order to proficiently stimulate a specific cerebral area it is of main importance the correct positioning and maintaining of the magnetic coil, while avoiding the mismatch due to subject head-coil relative movement. Hot Spot Hound is a novel robot-assisted experimental platform for enhancing TMS stimulation performance. It integrates a commercial optoelectronic neuronavigation system (E.M.S. srl, Italy) for gathering data on the relative pose (position and orientation) of subject's scalp and TMS coil, and a service robotic arm designed for human interaction (LWR system by KUKA, Germany). Besides integrating and synchronizing different platform sub-systems, we implement a control strategy to center the stimulation point and compensate for involuntary subject movements. Specifically, the proposed control maintains constant over time the homogeneous transformation matrix between the pose of the coil and of the head. The value of position stiffness has been chosen in order to assure the better compromise between coil position and orientation error, and the safety of the experimental subject. In this paper we show that Hot Spot Hound can provide coil position and orientation errors well beyond the ones achieved by manual experimenter, while assuring safety in the physical interaction with the stimulated subject.

Design, implementation and evaluation of an independent real-time safety layer for medical robotic systems using a force-torque-acceleration (FTA) sensor

PURPOSE

Most medical robotic systems require direct interaction or contact with the robot. Force-Torque (FT) sensors can easily be mounted to the robot to control the contact pressure. However, evaluation is often done in software, which leads to latencies.

METHODS

To overcome that, we developed an independent safety system, named FTA sensor, which is based on an FT sensor and an accelerometer. An embedded system (ES) runs a real-time monitoring system for continuously checking of the readings. In case of a collision or error, it instantaneously stops the robot via the robot's external emergency stop.

RESULTS

We found that the ES implementing the FTA sensor has a maximum latency of [Formula: see text] ms to trigger the robot's emergency stop. For the standard settings in the application of robotized transcranial magnetic stimulation, the robot will stop after at most 4 mm.

CONCLUSION

Therefore, it works as an independent safety layer preventing patient and/or operator from serious harm.