Neuromodulatory effects and reproducibility of the most widely used repetitive transcranial magnetic stimulation protocols

Height-dependent variation in corticospinal excitability modulation after active but not sham intermittent theta burst stimulation

Poor reproducibility and high inter-individual variability in responses to intermittent theta burst stimulation (iTBS) of the human motor cortex (M1) are matters of concern. Here we recruited 17 healthy young adults in a randomized, sham-controlled, crossover study. Transcranial magnetic stimulation (TMS)-elicited motor evoked potentials (MEPs) were measured pre-iTBS (T0) and post-iTBS at 4-7 (T1), 9-12 (T2), 17-20 (T3), and 27-30 minutes (T4) from the right first dorsal interosseous muscle. MEP grand average (MEPGA) was defined as the mean of the normalized-to-baseline MEPs at all timepoints post-iTBS. As secondary objectives, we measured blood pressure, heart rate, and capillary blood glucose pre-iTBS, and at 0 and 30 minutes post-iTBS. The TMSens_Q structured questionnaire was filled out at the end of each session. Two-way repeated ANOVA did not show a significant TIME×INTERVENTION interaction effect on MEP amplitude, MEP latency, blood pressure, heart rate, and blood glucose (p > 0.05). Sleepiness was the most reported TMSens_Q sensation (82.3 %) in both groups. Surprisingly, the subjects' height negatively correlated with the normalized MEP amplitudes at T3 (r = -0.65, p = 0.005), T4 (r = -0.66, p = 0.004), and MEPGA (r = -0.68, p = 0.003), with a trend correlation at T1 (r = -0.46, p = 0.062) and T2 (r = -0.46, p = 0.065) in the active but not sham group. In view of this, we urge future studies to delve deeper into the influence of height on neuroplasticity induction of the M1 representation of peripheral muscles. In the end, we highlight unique methodological considerations in our study protocol and future recommendations for M1-iTBS studies.

Assessing Neuromodulation Effects of Theta Burst Stimulation to the Prefrontal Cortex Using Transcranial Magnetic Stimulation Electroencephalography (TMS-EEG)

Theta burst stimulation (TBS), a form of repetitive transcranial magnetic stimulation (TMS), is capable of non-invasively modulating cortical excitability. TBS is gaining popularity as a therapeutic tool for psychiatric disorders such as depression, in which the dorsolateral prefrontal cortex (DLPFC) is the main therapeutic target. However, the neuromodulatory effects of TBS on prefrontal regions remain unclear. Concurrent transcranial magnetic stimulation and electroencephalography (TMS-EEG) can assess neuromodulation in non-motor regions using TMS-evoked potentials (TEPs) and event-related synchronisation/desynchronisation (ERS/D). We assessed 24 healthy participants (13 males, mean age 25.2 ± 9.9 years) in a single-blinded crossover study design, following intermittent TBS, continuous TBS and sham applied to the left DLPFC. TEPs and ERS/D were obtained at baseline and 2-, 15- and 30-min post-stimulation. Four TEP components (N40, P60, N100 and P200) and two frequency bands (theta and gamma) were analysed using mixed effects repeated measures models (MRMM). Results indicated no significant effects for any assessed components or frequency bands. Relative to sham, the largest TEP effect size was obtained for the N100 component at 15 min post-iTBS (d = -0.50), and the largest frequency effect was obtained for gamma ERS at 15 min post-cTBS (d = 0.53). These results were in the same direction but smaller than found in previous studies, suggesting that effect sizes of the neuromodulatory effects of TBS may be lower than previously reported.

Treating Depression With Repetitive Transcranial Magnetic Stimulation: A Clinician's Guide

Transcranial magnetic stimulation (TMS) applies electromagnetic pulses to stimulate cortical neurons. The antidepressant effect of the repetitive application of TMS (rTMS) was first shown nearly three decades ago. The therapeutic potential of TMS has been extensively investigated, mostly in treatment-resistant depression (TRD). Studies have extensively evaluated stimulation parameters, treatment schedules, methods to localize the stimulation target, and different magnetic coil designs engineered for desired stimulation breadth and depth. Several of these stimulation protocols and coils/devices have received U.S. Food and Drug Administration (FDA) clearance for application in TRD and other neuropsychiatric disorders, such as obsessive-compulsive disorder. Some stimulation protocols, while not FDA-cleared, have substantial clinical trial-derived evidence to support their safety and antidepressant efficacy. The proliferation of rTMS translational and clinical research has resulted in the field's advancement. This clinician-oriented review contains an overview of fundamental TMS principles, physiological effects, and studies of rTMS in TRD. Also discussed are two innovations that are increasingly applied in the clinic: theta burst stimulation and accelerated scheduling. A synthesis of the key clinical considerations given to patient assessment and safety, treatment setup, and the minimization and management of adverse effects is provided.

Repetitive transcranial magnetic stimulation modulates brain connectivity in children with self-limited epilepsy with centrotemporal spikes

OBJECTIVE

Self-limited epilepsy with centrotemporal spikes (SeLECTS) is a common pediatric syndrome in which interictal epileptiform discharges (IEDs) emerge from the motor cortex and children often develop language deficits. IEDs may induce these language deficits by pathologically enhancing brain connectivity. Using a sham-controlled design, we test the impact of inhibitory low-frequency repetitive transcranial magnetic stimulation (rTMS) on connectivity and IEDs in SeLECTS.

METHODS

Nineteen children participated in a cross-over study comparing active vs. sham motor cortex rTMS. Single pulses of TMS combined with EEG (spTMS-EEG) were applied to the motor cortex before and after rTMS to probe connectivity. Connectivity was quantified by calculating the weighted phase lag index (wPLI) between six regions of interest: bilateral motor cortices (implicated in SeLECTS) and bilateral inferior frontal and superior temporal regions (important for language). IED frequency before and after rTMS was also quantified.

RESULTS

Active, but not sham, rTMS decreased wPLI connectivity between multiple regions, with the greatest reductions seen in superior temporal connections in the stimulated hemisphere. IED frequency decreased after active but not sham rTMS.

SIGNIFICANCE

Low-frequency rTMS reduces pathologic hyperconnectivity and IEDs in children with SeLECTS, making it a promising avenue for therapeutic interventions for SeLECTS and potentially other pediatric epilepsy syndromes.

Multimodal response-predictor analysis for three non-invasive brain stimulation protocols

Non-invasive brain stimulation (NIBS) methods such as paired associative stimulation (PAS), transcranial direct current stimulation (tDCS), and transcranial alternating current stimulation (tACS) are used to modulate cortical excitability and reduce symptoms in a variety of psychiatric disorders. Recent studies have shown significant inter-individual variability in the physiological response to these techniques when they are applied over the hand representation of primary motor cortex (M1hand). The goal of the present study was to identify neurophysiological, neuroanatomical, and neurochemical baseline characteristics that may predict response to commonly used NIBS protocols using data from a previously published study (Therrien-Blanchet et al., 2023). To this end, PAS, anodal tDCS, and 20-Hz tACS were administered to healthy participants in a repeated measures design. Pre/Post differences in transcranial magnetic stimulation-induced input-output curves were used to quantify changes in corticospinal excitability. Primary predictors were late I-wave latency, cortical thickness (CT) of M1hand, and fractional anisotropy of the corticospinal tract (CSThand) originating from M1hand. Secondary exploratory analysis was performed with CT in areas outside motor cortex, diffusion MRI (dMRI) metrics of the CSThand, magnetic resonance spectroscopy measurements of GABA, glutamate, and n-acetyl aspartate of M1hand, baseline corticospinal excitability, and cranial circumference. Multiple regression analysis showed that none of the primary variables predicted intervention outcome for any of the NIBS protocols. Exploratory analysis revealed no significant correlation between predictor variables and PAS outcome. tDCS and tACS were significantly correlated with some baseline measures. These data suggest that modulation of cortical excitability following several NIBS protocols may not be easily predicted by baseline characteristics, underscoring the need for a better understanding of their mechanism of action. Significant exploratory associations need to be confirmed in larger samples and confirmatory designs.

Predicting Neuroplasticity Effects of Continuous Theta Burst Stimulation with Biomarkers from the Motor Evoked Potential TMS Input-Output Curve

The field of neuromodulation lacks predictors of individual differences in plasticity that influence responses to repetitive transcranial magnetic stimulation (rTMS). Continuous theta burst stimulation (cTBS), a form of rTMS known for its inhibitory effects, shows variable responses between individuals, potentially due to differences in neuroplasticity. Predicting individual cTBS effects could vastly enhance its clinical and experimental utility. This study explores whether motor evoked potential (MEP) input-output (IO) parameters measured prior to neuromodulation can predict motor cortex responses to cTBS. IO curves were sampled from healthy adults by recording MEPs over a range of single pulse TMS intensities to obtain parameters including MEP max and S 50 (midpoint intensity). Subjects later received cTBS over the same location of motor cortex and their MEPs before and after stimulation were compared. Both MEP max and S 50 predicted responses, significantly correlating (p<0.05, R 2 >0.25) with individuals' MEP changes at 10, 20, and 30 minutes after cTBS. Further, we introduced and validated an easily implementable biomarker that does not require the time-consuming sampling of full IO curve: MEP 130RMT (median of 10 MEPs at 130% RMT). MEP 130RMT was also a strong predictor of cTBS response (p<0.005, R 2 >0.3). Head-to-head comparison against a previously studied genetic biomarker of rTMS responses (BDNF polymorphism) showed that IO based predictors had a superior performance in explaining more response variability. Thus, IO curves derived prior to cTBS administration can reliably predict cTBS-induced changes in cortical excitability. This work points toward an accessible strategy for tailoring stimulation procedures in both diagnostic and therapeutic applications of rTMS, and potentially boosting response rate to other brain stimulation approaches.

HIGHLIGHTS

Baseline TMS-MEP Input-Output (IO) Curve parameters significantly predict MEP responses to M1 cTBS. Higher MEP max at baseline predicts more robust inhibitory response to cTBS, while higher midpoint intensity (S 50 ) is associated with less response. D We developed and validated a new biomarker MEP 130RMT , which predicts cTBS response using just 10 baseline MEPs from single TMS pulses of 130% RMT intensity. Head to head comparison against BDNF genotyping shows superior performance of IO biomarkers.

Reward signals in the motor cortex: from biology to neurotechnology

Over the past decade, research has shown that the primary motor cortex (M1), the brain's main output for movement, also responds to rewards. These reward signals may shape motor output in its final stages, influencing movement invigoration and motor learning. In this Perspective, we highlight the functional roles of M1 reward signals and propose how they could guide advances in neurotechnologies for movement restoration, specifically brain-computer interfaces and non-invasive brain stimulation. Understanding M1 reward signals may open new avenues for enhancing motor control and rehabilitation.

Transcranial magnetic stimulation for obsessive-compulsive disorder and post-traumatic stress disorder: A comprehensive systematic review and analysis of therapeutic benefits, cortical targets, and psychopathophysiological mechanisms

Transcranial magnetic stimulation (TMS) is a safe non-invasive treatment technique. We systematically reviewed randomised controlled trials (RCTs) applying TMS in obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) to analyse its therapeutic benefits and explore the relationship between cortical target and psychopathophysiology. We included 47 randomised controlled trials (35 for OCD) and found a 22.7 % symptom improvement for OCD and 29.4 % for PTSD. Eight cortical targets were investigated for OCD and four for PTSD, yielding similar results. Bilateral dlPFC-TMS exhibited the greatest symptom change (32.3 % for OCD, N = 4 studies; 35.7 % for PTSD, N = 1 studies), followed by right dlPFC-TMS (24.4 % for OCD, N = 8; 26.7 % for PTSD, N = 10), and left dlPFC-TMS (22.9 % for OCD, N = 6; 23.1 % for PTSD, N = 1). mPFC-TMS showed promising results, although evidence is limited (N = 2 studies each for OCD and PTSD) and findings for PTSD were conflicting. Despite clinical improvement, reviewed reports lacked a consistent and solid rationale for cortical target selection, revealing a gap in TMS research that complicates the interpretation of findings and hinders TMS development and optimisation. Future research should adopt a hypothesis-driven approach rather than relying solely on correlations from imaging studies, integrating neurobiological processes with affective, behavioural, and cognitive states, thereby doing justice to the complexity of human experience and mental illness.

Increase in beta frequency phase synchronization and power after a session of high frequency repetitive transcranial magnetic stimulation to the primary motor cortex

High-frequency repetitive transcranial magnetic stimulation (rTMS) to the primary motor cortex (M1) is used to treat several neuropsychiatric disorders, but the detailed temporal dynamics of its effects on cortical connectivity remain unclear. Here, we stimulated four cortical targets used for rTMS (M1; dorsolateral-prefrontal cortex, DLPFC; anterior cingulate cortex, ACC; posterosuperior insula, PSI) with TMS coupled with high-density electroencephalography (TMS-EEG) to measure cortical excitability and oscillatory dynamics before and after active- and sham-M1-rTMS. Before and immediately after active or sham M1-rTMS (15 ​min, 3000 pulses at 10 ​Hz), single-pulse TMS-evoked EEG was recorded at the four targets in 20 healthy individuals. Cortical excitability and oscillatory measures were extracted at the main frequency bands (α [8-13 ​Hz], low-β [14-24 ​Hz], high-β [25-35 ​Hz]). Active-M1-rTMS increased high-β synchronization in electrodes near the stimulation area and remotely, in the contralateral hemisphere (p ​= ​0.026). Increased high-β synchronization (48-83 ​ms after TMS-EEG stimulation) was succeeded by enhancement in low-β power (86-144 ​ms after TMS-EEG stimulation) both locally and in the contralateral hemisphere (p ​= ​0.006). No significant differences were observed in stimulating the DLPFC, ACC, or PSI by TMS-EEG. M1-rTMS engaged a sequence of enhanced phase synchronization, followed by an increase in power occurring within M1, which spread to remote areas and persisted after the end of the stimulation session. These results are relevant to understanding the M1 neuroplastic effects of rTMS in health and may help in the development of informed rTMS therapies in disease.

A Comprehensive Overview of the Current Status and Advancements in Various Treatment Strategies against Epilepsy

Epilepsy affects more than 70 million individuals of all ages worldwide and remains one of the most severe chronic noncommunicable neurological diseases globally. Several neurotransmitters, membrane protein channels, receptors, enzymes, and, more recently noted, various pathways, such as inflammatory and mTORC complexes, play significant roles in the initiation and propagation of seizures. Over the past two decades, significant developments have been made in the diagnosis and treatment of epilepsy. Various pharmacological drugs with diverse mechanisms of action and other treatment options have been developed to control seizures and treat epilepsy. These options include surgical treatment, nanomedicine, gene therapy, natural products, nervous stimulation, a ketogenic diet, gut microbiota, etc., which are in various developmental stages. Despite a plethora of drugs and other treatment options, one-third of affected individuals are resistant to current medications, while the majority of approved drugs have severe side effects, and significant changes can occur, such as pharmacoresistance, effects on cognition, long-term problems, drug interactions, risks of poor adherence, specific effects for certain medications, and psychological complications. Therefore, the development of new drugs and other treatment options that have no or minimal adverse effects is needed to combat this deadly disease. In this Review, we comprehensively summarize and explain all of the treatment options that have been approved or are in developmental stages for epilepsy as well as their status in clinical trials and advancements.

Continuous theta burst stimulation at 30 hz does not modulate cortical excitability in a sham-controlled study

Theta burst stimulation (TBS) can modulate cortical excitability but suffers from high inter-subject variability. Modified TBS frequency patterns (30 Hz) showed consistent inhibitory aftereffects, but further research into the time course of these effects is needed. This study aimed to investigate the efficacy of a 30 Hz continuous TBS (cTBS) protocol. Participants (n = 20) underwent an experimental session (real cTBS) and a control session (sham cTBS). To assess cortical excitability, Transcranial Magnetic Stimulation was applied over the primary motor cortex before cTBS, and at five timepoints after cTBS. Percentage change (PC) to baseline was analysed using a Linear Mixed Model. No difference in PC was found between real and sham cTBS (p = 0.696). Our results demonstrate a significant increase in PC over time (p = 0.006) at 30, (p = 0.01), 45 (p = 0.027), and 55 min (p = 0.024) post cTBS, irrespective of condition. Secondary analysis dividing the sample into responders and paradox-responders showed no significant predictors for cTBS responsiveness. We could not replicate previously reported suppressive effects of 30 Hz cTBS. Increases in MEP amplitudes over a 60-minute time window were independent of stimulation condition and marked by high inter-subject variability. Validations of modified TBS protocols are further needed to replicate findings and understand mechanisms underlying individuals' responsiveness.

Transcranial Magnetic Stimulation for Posttraumatic Stress Disorder and Generalized Anxiety Disorder

Posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD) are debilitating psychiatric disorders. While treatments are often effective, many patients do not adequately respond or experience significant side effects. Transcranial magnetic stimulation (TMS) is an emerging approach for treating PTSD and GAD. Several randomized clinical trials have demonstrated that TMS over the dorsolateral prefrontal cortex may be efficacious in reducing psychiatric symptoms; however, results are inconsistent regarding whether any parameter or treatment paradigm is superior. Other RCTs have targeted novel brain regions using newer TMS modalities. Combining TMS with psychotherapy may augment response in patients with PTSD, yet results are inconclusive. Little research has been done on TMS in combination with psychotherapy for GAD, indicating a need for further investigation. Future studies may assess TMS parameter optimization for enhancing effectiveness and improving therapeutic response duration. Identifying response biomarkers through functional magnetic resonance imaging and electroencephalography may offer a means to predict and monitor clinical response as precision methods to improve treatment response.

The role of white matter variability in TMS neuromodulatory effects

BACKGROUND

Transcranial Magnetic Stimulation (TMS) is a widely used tool to explore the causal role of focal brain regions in cognitive processing. TMS effects over attentional processes are consistent and replicable, while at the same time subjected to individual variability. This individual variability needs to be understood to better comprehend TMS effects, and most importantly, its clinical applications.

OBJECTIVE

This study aimed to explore the role of white matter variability in TMS neuromodulatory effects on behavior in healthy participants (N = 50).

METHODS

Participants completed an attentional task in which orienting and alerting cues preceded near-threshold targets. Continuous Theta Burst Stimulation (cTBS) was applied over the left frontal eye field (FEF) or an active vertex condition. White matter was explored with diffusion-weighted imaging tractography and Tract-Based Spatial Statistics (TBSS).

RESULTS

Behaviorally, TMS over the left FEF slowed down reaction times (especially in the alerting task), impaired accuracy in the objective task, and reduced the proportion of seen targets (as compared to the vertex condition). Attentional effects increased, overall, when TMS was applied to the left FEF as compared to the vertex condition. Correlations between white matter and TMS effects showed i) reduced TMS effects associated with the microstructural properties of long-range white matter pathways such as the superior longitudinal fasciculus (SLF), and interhemispheric fibers of the corpus callosum (CC), and ii) increased TMS effects in participants with high integrity of the CC connecting the stimulated region with the opposite hemisphere. Additionally, variability in attentional effects was also related to white matter, showing iii) increased alerting effects in participants with low integrity of association, commissural, and projection fibers, and iv) increased orienting effects in participants with high integrity of the right SLF III.

CONCLUSION

All these observations highlight the importance of taking into account individual variability in white matter for the understanding of cognitive processing and brain neuromodulation effects.

Repetitive Transcranial Magnetic Stimulation Modulates Brain Connectivity in Children with Self-limited Epilepsy with Centrotemporal Spikes

Objective

Interictal epileptiform discharges (IEDs) alter brain connectivity in children with epilepsy; this connectivity change may be a mechanism by which epilepsy induces cognitive deficits. Here, we test whether repetitive transcranial magnetic stimulation (rTMS), a non-invasive neuromodulation technique, modulates connectivity and reduces IEDs in children with epilepsy.

Methods

Nineteen children with self-limited epilepsy with centrotemporal spikes (SeLECTS) participated in a cross-over study comparing the impact of active vs. sham rTMS on IEDs and brain connectivity. SeLECTS is an epilepsy syndrome affecting the motor cortex, and prior studies show that motor cortices become pathologically hyper-connected to frontal and temporal language cortices. Using a crossover design, we compared the effect of single doses of active versus sham motor cortex rTMS. Connectivity, which was quantified by the weighted phase lag index (wPLI), was measured before and after rTMS using single pulses of TMS combined with EEG (spTMS-EEG). Analyses focused on six regions: bilateral motor cortices and bilateral inferior frontal and superior temporal regions. IEDs were counted in the five minutes before and after rTMS.

Results

Active, but not sham, rTMS significantly and globally decreased wPLI connectivity between multiple regions, with the greatest reductions seen in the superior temporal region connections in the stimulated hemisphere. Additionally, there was a trend suggesting that rTMS decreases IED frequency.

Interpretation

These findings underscore the potential of low-frequency rTMS to target pathologic hyperconnectivity and reduce IEDs in children with SeLECTS and potentially other pediatric epilepsy syndromes, offering a promising avenue for therapeutic intervention.

Exploring Motor Network Connectivity in State-Dependent Transcranial Magnetic Stimulation: A Proof-of-Concept Study

State-dependent non-invasive brain stimulation (NIBS) informed by electroencephalography (EEG) has contributed to the understanding of NIBS inter-subject and inter-session variability. While these approaches focus on local EEG characteristics, it is acknowledged that the brain exhibits an intrinsic long-range dynamic organization in networks. This proof-of-concept study explores whether EEG connectivity of the primary motor cortex (M1) in the pre-stimulation period aligns with the Motor Network (MN) and how the MN state affects responses to the transcranial magnetic stimulation (TMS) of M1. One thousand suprathreshold TMS pulses were delivered to the left M1 in eight subjects at rest, with simultaneous EEG. Motor-evoked potentials (MEPs) were measured from the right hand. The source space functional connectivity of the left M1 to the whole brain was assessed using the imaginary part of the phase locking value at the frequency of the sensorimotor μ-rhythm in a 1 s window before the pulse. Group-level connectivity revealed functional links between the left M1, left supplementary motor area, and right M1. Also, pulses delivered at high MN connectivity states result in a greater MEP amplitude compared to low connectivity states. At the single-subject level, this relation is more highly expressed in subjects that feature an overall high cortico-spinal excitability. In conclusion, this study paves the way for MN connectivity-based NIBS.

Variability of pulse width in transcranial magnetic stimulation

Objective.There is a high variability in the physiological effects of transcranial magnetic brain stimulation, resulting in limited generalizability of measurements. The cause of the variability is assumed to be primarily based on differences in brain function and structure of the stimulated individuals, while the variability of the physical properties of the magnetic stimulus has so far been largely neglected. Thus, this study is dedicated to the systematic investigation of variability in the pulse width of different TMS pulse sources at different stimulation intensities.Approach.The pulse widths of seven MagVenture® pulse sources were measured at the output of 10%-100% stimulation intensity in 10% increments via Near Field Probe and oscilloscope. The same C-B60 coil was used to deliver biphasic pulses. Pulse widths were compared between pulse sources and stimulation intensities.Main results.The mean sample pulse width was 288.11 ± 0.37µs, which deviates from the value of 280µs specified by the manufacturer. The pulse sources and stimulation intensities differ in their average pulse width (p's< .001). However, the coefficient of variation within the groups (pulse source; stimulation intensity) were moderately low (CV = 0.13%-0.67%).Significance.The technical parameter of pulse width shows deviations from the proposed manufacturer value. According to our data, within a pulse source of the same manufacturer, the pulse width variability is minimal, but varies between pulse sources of the same and other pulse source models. Whether the observed variability in pulse width has potential physiological relevance was tested in a pilot experiment on a single healthy subject, showing no significant difference in motor evoked potential amplitude and significant difference in latencies. Future research should systematically investigate the physiological effects of different pulse lengths. Furthermore, potential hardware ageing effects and pulse amplitude should be investigated.

Current perspectives on neuromodulation in ALS patients: A systematic review and meta-analysis

Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease that affects motor neurons, resulting in muscle weakness, paralysis, and eventually patient mortality. In recent years, neuromodulation techniques have emerged as promising potential therapeutic approaches to slow disease progression and improve the quality of life of ALS patients. A systematic review was conducted until August 8, 2023, to evaluate the neuromodulation methods used and their potential in the treatment of ALS. The search strategy was applied in the Cochrane Central database, incorporating results from other databases such as PubMed, Embase, CTgov, CINAHL, and ICTRP. Following the exclusion of papers that did not fulfil the inclusion criteria, a total of 2090 records were found, leaving a total of 10 studies. R software was used to conduct meta-analyses based on the effect sizes between the experimental and control groups. This revealed differences in muscle stretch measures with manual muscle testing (p = 0.012) and resting motor threshold (p = 0.0457), but not with voluntary isometric contraction (p = 0.1883). The functionality of ALS was also different (p = 0.007), but not the quality of life. Although intracortical facilitation was not seen in motor cortex 1 (M1) (p = 0.1338), short-interval intracortical inhibition of M1 was significant (p = 0.0001). BDNF showed no differences that were statistically significant (p = 0.2297). Neuromodulation-based treatments are proposed as a promising therapeutic approach for ALS that can produce effects on muscle function, spasticity, and intracortical connections through electrical, magnetic, and photonic stimulation. Photobiomodulation stands out as an innovative approach that uses specific wavelengths to influence mitochondria, with the aim of improving mitochondrial function and reducing excitotoxicity. The lack of reliable placebo controls and the variation in stimulation frequency are some of the drawbacks of neuromodulation.

Limited evidence for reliability of low and high frequency rTMS over the motor cortex

OBJECTIVE

The aim of this study was to investigate the reliability of low-frequency and high-frequency repetitive transcranial magnetic stimulation (rTMS) on healthy individuals over the motor cortex. A secondary outcome was the assessment if low-frequency rTMS results in inhibition and high-frequency rTMS results in facilitation.

METHODS

In this experiment, 30 healthy participants received on four consecutive days one session each with application of 1 Hz or 20 Hz rTMS over the left motor cortex. 1 Hz and 20 Hz were applied in alternating order, whereby the starting frequency was randomized. Motor evoked potentials (MEPs) were measured before and after each session. Reliability measures were intraclass and Pearson's correlation coefficient (ICC and r).

RESULTS

ICCs and r values were low to moderate. Notably, within subgroups of less confounded measures, we found good r values for 20 Hz rTMS. The group-level analysis did not demonstrate a clear low-frequency inhibition and high-frequency facilitation pattern. At the single-subject level, only one participant exhibited significant changes consistent with the expected pattern, with concurrent decreases in MEPs following 1 Hz sessions and increases following 20 Hz sessions.

CONCLUSION

The investigated neuromodulatory protocols show low to moderate reliability. Results are questioning the low-frequency inhibition and high-frequency facilitation pattern.

SIGNIFICANCE

Methodological improvements for the usage of rTMS are necessary to increase validity and reliability of non-invasive brain stimulation.

Systematic Evaluation of the Effects of Voluntary Activation on Lower Extremity Motor Thresholds

The purpose of this investigation was to elucidate the relationship between the resting motor threshold (rMT) and active motor threshold (aMT). A cross-sectional comparison of MTs measured at four states of lower extremity muscle activation was conducted: resting, 5% maximal voluntary contraction (MVC), 10%MVC, and standing. MTs were measured at the tibialis anterior in the ipsilesional and contralesional limbs in participants in the chronic phase (>6 months) of stroke (n = 11) and in the dominant limb of healthy controls (n = 11). To compare across activation levels, the responses were standardized using averaged peak-to-peak background electromyography (EMG) activity measured at 10%MVC + 2SD for each participant, in addition to the traditional 0.05 mV criterion for rMT (rMT50). In all participants, as muscle activation increased, the least square mean estimates of MTs decreased (contralesional: p = 0.008; ipsilesional: p = 0.0015, healthy dominant: p < 0.0001). In healthy controls, rMT50 was significantly different from all other MTs (p < 0.0344), while in stroke, there were no differences in either limb (p > 0.10). This investigation highlights the relationship between rMT and aMTs, which is important as many stroke survivors do not present with an rMT, necessitating the use of an aMT. Future works may consider the use of the standardized criterion that accounted for background EMG activity across activation levels.