Impaired Cerebellum to Primary Motor Cortex Associative Plasticity in Parkinson's Disease and Spinocerebellar Ataxia Type 3

Transcranial magnetic stimulation neurophysiology in patients with non-Alzheimer's neurodegenerative diseases: A systematic review and meta-analysis

Non-Alzheimer's dementia (NAD) accounts for 30% of all neurodegenerative conditions and is characterized by cognitive decline beyond mere memory dysfunction. Diagnosing NAD remains challenging due to the lack of established biomarkers. Transcranial magnetic stimulation (TMS) is a non-invasive neurophysiological tool that enables the investigation of cortical excitability in the human brain. Paired-pulse TMS paradigms include short- and long-interval intracortical inhibition (SICI/LICI), intracortical facilitation (ICF), and short-latency afferent inhibition (SAI), which can assess neurophysiological functions of GABAergic, glutamatergic, and cholinergic neural circuits, respectively. We conducted the first systematic review and meta-analysis to compare these TMS indices among patients with NAD and healthy controls. Our meta-analyses indicated that TMS neurophysiological examinations revealed decreased glutamatergic function in patients with frontotemporal dementia (FTD) and decreased GABAergic function in patients with FTD, progressive supranuclear palsy, Huntington's disease, cortico-basal syndrome, and multiple system atrophy-parkinsonian type. In addition, decreased cholinergic function was found in dementia with Lewy body and vascular dementia. These results suggest the potential of TMS as an additional diagnostic tool to differentiate NAD.

Targeting Sensory and Motor Integration for Recovery of Movement After CNS Injury

The central nervous system (CNS) integrates sensory and motor information to acquire skilled movements, known as sensory-motor integration (SMI). The reciprocal interaction of the sensory and motor systems is a prerequisite for learning and performing skilled movement. Injury to various nodes of the sensorimotor network causes impairment in movement execution and learning. Stimulation methods have been developed to directly recruit the sensorimotor system and modulate neural networks to restore movement after CNS injury. Part 1 reviews the main processes and anatomical interactions responsible for SMI in health. Part 2 details the effects of injury on sites critical for SMI, including the spinal cord, cerebellum, and cerebral cortex. Finally, Part 3 reviews the application of activity-dependent plasticity in ways that specifically target integration of sensory and motor systems. Understanding of each of these components is needed to advance strategies targeting SMI to improve rehabilitation in humans after injury.

Rehabilitation in movement disorders: From basic mechanisms to clinical strategies

Movement disorders encompass a variety of conditions affecting the nervous system at multiple levels. The pathologic processes underlying movement disorders alter the normal neural functions and could lead to aberrant neuroplastic changes and to clinical phenomenology that is not expressed only through mere motor symptoms. Given this complexity, the responsiveness to pharmacologic and surgical therapies is often disappointing. Growing evidence supports the efficacy of neurorehabilitation for the treatment of movement disorders. Specific form of training involving both goal-based practice and aerobic training could drive and modulate neuroplasticity in order to restore the circuitries dysfunctions and to achieve behavioral gains. This chapter provides an overview of the alterations expressed in some movement disorders in terms of clinical signs and symptoms and plasticity, and suggests which ones and why tailored rehabilitation strategies should be adopted for the management of the different movement disorders.

Neurophysiological features in spinocerebellar ataxia type 2: Prospects for novel biomarkers

Electrophysiological biomarkers are useful to assess the degeneration and progression of the nervous system in pre-ataxic and ataxic stages of the Spinocerebellar Ataxia Type 2 (SCA2). These biomarkers are essentially defined by their clinical significance, discriminating patients and/or preclinical subjects from healthy controls in cross-sectional studies, their significant changes over time in longitudinal studies, and their correlation with the cytosine-guanine-adenine (CAG) repeat expansion and/or clinical ataxia scores, time of evolution and time to ataxia onset. We classified electrophysiological biomarkers into three main types: (1) preclinical, (2) disease progression and (3) genetic damage. We review the data that identify sural nerve potential amplitude, maximum saccadic velocity, sleep efficiency, rapid eye movement (REM) sleep percentage, K-complex density, REM sleep without atonia percentage, corticomuscular coherence, central motor conduction time, visual P300 latency, and antisaccadic error correction latency as reliable preclinical, progression and/or genetic damage biomarkers of SCA2. These electrophysiological biomarkers will facilitate the conduction of clinical trials that test the efficacy of emerging treatments in SCA2.

Broad Influence of Mutant Ataxin-3 on the Proteome of the Adult Brain, Young Neurons, and Axons Reveals Central Molecular Processes and Biomarkers in SCA3/MJD Using Knock-In Mouse Model

Spinocerebellar ataxia type 3 (SCA3/MJD) is caused by CAG expansion mutation resulting in a long polyQ domain in mutant ataxin-3. The mutant protein is a special type of protease, deubiquitinase, which may indicate its prominent impact on the regulation of cellular proteins levels and activity. Yet, the global model picture of SCA3 disease progression on the protein level, molecular pathways in the brain, and neurons, is largely unknown. Here, we investigated the molecular SCA3 mechanism using an interdisciplinary research paradigm combining behavioral and molecular aspects of SCA3 in the knock-in ki91 model. We used the behavior, brain magnetic resonance imaging (MRI) and brain tissue examination to correlate the disease stages with brain proteomics, precise axonal proteomics, neuronal energy recordings, and labeling of vesicles. We have demonstrated that altered metabolic and mitochondrial proteins in the brain and the lack of weight gain in Ki91 SCA3/MJD mice is reflected by the failure of energy metabolism recorded in neonatal SCA3 cerebellar neurons. We have determined that further, during disease progression, proteins responsible for metabolism, cytoskeletal architecture, vesicular, and axonal transport are disturbed, revealing axons as one of the essential cell compartments in SCA3 pathogenesis. Therefore we focus on SCA3 pathogenesis in axonal and somatodendritic compartments revealing highly increased axonal localization of protein synthesis machinery, including ribosomes, translation factors, and RNA binding proteins, while the level of proteins responsible for cellular transport and mitochondria was decreased. We demonstrate the accumulation of axonal vesicles in neonatal SCA3 cerebellar neurons and increased phosphorylation of SMI-312 positive adult cerebellar axons, which indicate axonal dysfunction in SCA3. In summary, the SCA3 disease mechanism is based on the broad influence of mutant ataxin-3 on the neuronal proteome. Processes central in our SCA3 model include disturbed localization of proteins between axonal and somatodendritic compartment, early neuronal energy deficit, altered neuronal cytoskeletal structure, an overabundance of various components of protein synthesis machinery in axons.

The Ties That Bind: Aberrant Plasticity and Networks Dysfunction in Movement Disorders-Implications for Rehabilitation

Background: Movement disorders encompass various conditions affecting the nervous system. The pathological processes underlying movement disorders lead to aberrant synaptic plastic changes, which in turn alter the functioning of large-scale brain networks. Therefore, clinical phenomenology does not only entail motor symptoms but also cognitive and motivational disturbances. The result is the disruption of motor learning and motor behavior. Due to this complexity, the responsiveness to standard therapies could be disappointing. Specific forms of rehabilitation entailing goal-based practice, aerobic training, and the use of noninvasive brain stimulation techniques could "restore" neuroplasticity at motor-cognitive circuitries, leading to clinical gains. This is probably associated with modulations occurring at both molecular (synaptic) and circuitry levels (networks). Several gaps remain in our understanding of the relationships among plasticity and neural networks and how neurorehabilitation could promote clinical gains is still unclear. Purposes: In this review, we outline first the networks involved in motor learning and behavior and analyze which mechanisms link the pathological synaptic plastic changes with these networks' disruption in movement disorders. Therefore, we provide theoretical and practical bases to be applied for treatment in rehabilitation.

Cerebellar rTMS and PAS effectively induce cerebellar plasticity

Non-invasive brain stimulation techniques including repetitive transcranial magnetic stimulation (rTMS), continuous theta-burst stimulation (cTBS), paired associative stimulation (PAS), and transcranial direct current stimulation (tDCS) have been applied over the cerebellum to induce plasticity and gain insights into the interaction of the cerebellum with neo-cortical structures including the motor cortex. We compared the effects of 1 Hz rTMS, cTBS, PAS and tDCS given over the cerebellum on motor cortical excitability and interactions between the cerebellum and dorsal premotor cortex / primary motor cortex in two within subject designs in healthy controls. In experiment 1, rTMS, cTBS, PAS, and tDCS were applied over the cerebellum in 20 healthy subjects. In experiment 2, rTMS and PAS were compared to sham conditions in another group of 20 healthy subjects. In experiment 1, PAS reduced cortical excitability determined by motor evoked potentials (MEP) amplitudes, whereas rTMS increased motor thresholds and facilitated dorsal premotor-motor and cerebellum-motor cortex interactions. TDCS and cTBS had no significant effects. In experiment 2, MEP amplitudes increased after rTMS and motor thresholds following PAS. Analysis of all participants who received rTMS and PAS showed that MEP amplitudes were reduced after PAS and increased following rTMS. rTMS also caused facilitation of dorsal premotor-motor cortex and cerebellum-motor cortex interactions. In summary, cerebellar 1 Hz rTMS and PAS can effectively induce plasticity in cerebello-(premotor)-motor pathways provided larger samples are studied.

Inverse associations between cerebellar inhibition and motor impairment in spinocerebellar ataxia type 3

BACKGROUND

Cerebellar ataxia generally results from a lesion disrupting the corticopontocerebellar or cerebellothalamocortical tract. The cerebellar inhibition (CBI) paradigm represents a dual-coil transcranial magnetic stimulation protocol that interrogates the integrity of the latter pathway. Whether CBI has clinical relevance in ataxia patients remains largely unknown because associations with pertinent disease severity measures in etiologically homogeneous cohorts have not been previously examined.

OBJECTIVE

To investigate if CBI correlates with clinical and functional indices of disease severity in individuals with spinocerebellar ataxia type 3 (SCA3).

METHODS

CBI was assessed in fourteen SCA3 patients by paired-pulse cerebellar-motor cortex (M1) stimulation using interstimulus intervals of 3, 5, and 10 ms. Correlation coefficients were determined between CBI and ataxia severity, manual dexterity, and walking speed.

RESULTS

Suppression of M1 excitability occurred 5 ms following a contralateral cerebellar conditioning stimulus in SCA3 patients, but, on average, CBI was significantly reduced as compared to a healthy control group from the literature (p < 0.001). A significant association was found between decreased CBI levels and higher Scale for the Assessment and Rating of Ataxia (SARA) scores (r = -0.62, p = 0.019). CBI was negatively correlated with axial, appendicular, and speech subscores, as well as with nine-hole peg test performance (r = -0.69, p = 0.006). No association was observed between CBI and walking speed. As expected, there were no significant clinical-neurophysiological correlations at 3 and 10 ms interstimulus intervals.

CONCLUSION

Our results provide the first neurophysiological evidence for an inverse association between cerebellothalamocortical tract integrity, as reflected by reduced levels of CBI, and ataxia severity in SCA3 patients. Longitudinal studies are required to evaluate if CBI could serve as a marker of disease progression.

Human Theta Burst Stimulation Combined with Subsequent Electroacupuncture Increases Corticospinal Excitability

Objective

Intermittent theta burst stimulation (iTBS) is a widely used noninvasive brain stimulation for the facilitation of corticospinal excitability (CSE). Previous studies have shown that acupuncture applied to acupoints associated with motor function in healthy people can reduce the amplitude of the motor-evoked potentials (MEPs), which reflects the inhibition of CSE. In our work, we wanted to test whether the combination of iTBS and electroacupuncture (EA) would have different effects on CSE in humans.

Methods

A single-blind sham-controlled crossover design study was conducted on 20 healthy subjects. Subjects received 20 minutes' sham or real EA stimulation immediately after sham or real iTBS. MEPs, short-interval intracortical inhibition (SICI), intracortical facilitation (ICF), cortical silent period (CSP), and central motor conduction time (CMCT) were recorded before each trial, and immediately, 20 minutes, and 40 minutes after the end of stimulation.

Results

In the sham iTBS group, EA produced a reduction in MEPs amplitude, lasting approximately 40 minutes, while in the real iTBS group, EA significantly increased MEPs amplitude beyond 40 minutes after the end of stimulation. In sham EA group, the recorded MEPs amplitude showed no significant trend over time compared to baseline. Among all experiments, there were no significant changes in SICI, ICF, CSP, CMCT, etc.

Conclusion

These data indicate that immediate application of EA after iTBS significantly increased corticospinal excitability. This trial was registered in the Chinese Clinical Trial Registry (registration no. ChiCTR1900025348).

Cerebral Cortical Activity Following Non-invasive Cerebellar Stimulation-a Systematic Review of Combined TMS and EEG Studies

The cerebellum sends dense projections to both motor and non-motor regions of the cerebral cortex via the cerebellarthalamocortical tract. The integrity of this tract is crucial for healthy motor and cognitive function. This systematic review examines research using transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) to the cerebellum with combined cortical electroencephalography (EEG) to explore the temporal features of cerebellar-cortical connectivity. A detailed discussion of the outcomes and limitations of the studies meeting review criteria is presented. Databases were searched between 1 December 2017 and 6 December 2017, with Scopus alerts current as of 23 July 2019. Of the 407 studies initially identified, 10 met review criteria. Findings suggested that cerebellar-cortical assessment is suited to combined TMS and EEG, although work is required to ensure experimental procedures are optimal for eliciting a reliable cerebellar response from stimulation. A distinct variation in methodologies and outcome measures employed across studies, and small sample sizes limited the conclusions that could be drawn regarding the electrophysiological signatures of cerebellar-cortical communication. This review highlights the need for stringent protocols and methodologies for cerebellar-cortical assessments via combined TMS and EEG. With these in place, combined TMS and EEG will provide a valuable means for exploring cerebellar connectivity with a wide range of cortical sites. Assessments have the potential to aid in the understanding of motor and cognitive function in both healthy and clinical groups, and provide insights into long-range neural communication generally.

Convergent Associative Motor Cortical Plasticity Induced by Conditional Somatosensory and Motor Reaction Afferents

Objective: Associative motor cortical plasticity can be non-invasively induced by paired median nerve electric stimulation and transcranial magnetic stimulation (TMS) of the primary motor cortex (M1). This study investigates whether a simultaneous motor reaction of the other hand advances the associative plasticity in M1.

Methods: Twenty-four right-handed subjects received conventional paired associative stimulation (PAS) and PAS with simultaneous motor reaction (PASmr) with at least a 1-week interval. The PASmr protocol additionally included left abductor pollicis brevis muscle movement responding to a digital sound. The motor reaction time was individually measured. The M1 excitability was examined by the motor evoked potential (MEP), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF) before and after the PAS protocols.

Results: The conventional PAS protocol significantly facilitated MEP and suppressed SICI. A negative correlation between the reaction time and the MEP change, and a positive correlation between the reaction time and the ICF change were found in the PASmr protocol. By subgrouping analysis, we further found significant facilitation of MEP and a reduction of ICF in the subjects with fast reaction times but not in those with slow reaction times.

Conclusion: Synchronized motor reaction ipsilateral to the stimulated M1 induces associative M1 motor plasticity through the spike-timing dependent principle. MEP and ICF change could represent this kind of plasticity. The current findings provide a novel insight into designing rehabilitation programs concerning motor function.

Functional Alteration of Cerebello-Cerebral Coupling in an Experimental Mouse Model of Parkinson's Disease

In Parkinson's disease, the degeneration of the midbrain dopaminergic neurons is consistently associated with modified metabolic activity in the cerebellum. Here we examined the functional reorganization taking place in the cerebello-cerebral circuit in a murine model of Parkinson's disease with 6-OHDA lesion of midbrain dopaminergic neurons. Cerebellar optogenetic stimulations evoked similar movements in control and lesioned mice, suggesting a normal coupling of cerebellum to the motor effectors after the lesion. In freely moving animals, the firing rate in the primary motor cortex was decreased after the lesion, while cerebellar nuclei neurons showed an increased firing rate. This increase may result from reduced inhibitory Purkinje cells inputs, since a population of slow and irregular Purkinje cells was observed in the cerebellar hemispheres of lesioned animals. Moreover, cerebellar stimulations generated smaller electrocortical responses in the motor cortex of lesioned animals suggesting a weaker cerebello-cerebral coupling. Overall these results indicate the presence of functional changes in the cerebello-cerebral circuit, but their ability to correct cortical dysfunction may be limited due to functional uncoupling between the cerebellum and cerebral cortex.

Skeletal muscle transcriptional networks linked to type I myofiber grouping in Parkinson's disease

Parkinson's disease (PD) is a common neurodegenerative disorder impacting cognition, movement, and quality of life in >10 million individuals worldwide. We recently characterized and quantified a skeletal muscle pathology in PD represented by exaggerated type I myofiber grouping presumed to result from denervation-reinnervation processes. Our previous findings indicated that impaired neuromuscular junction integrity may be involved in type I grouping, which is associated with excessive motor unit activation during weight-bearing tasks. In this study, we performed transcriptional profiling to test the hypothesis that type I grouping severity would link to distinct gene expression networks. We generated transcriptome-wide poly(A) RNA-Seq data from skeletal muscle of individuals with PD [n = 12 (9 men, 3 women); 67 ± 2 yr], age- and sex-matched older adults (n = 12; 68 ± 2 yr), and sex-matched young adults (n = 12; 30 ± 1 yr). Differentially expressed genes were evaluated across cohorts. Weighted gene correlation network analysis (WGCNA) was performed to identify gene networks most correlated with indicators of abnormal type I grouping. Among coexpression networks mapping to phenotypes pathologically increased in PD muscle, one network was highly significantly correlated to type I myofiber group size and another to percentage of type I myofibers found in groups. Annotation of coexpressed networks revealed that type I grouping is associated with altered expression of genes involved in neural development, postsynaptic signaling, cell cycle regulation and cell survival, protein and energy metabolism, inflammation/immunity, and posttranscriptional regulation (microRNAs). These transcriptomic findings suggest that skeletal muscle may play an active role in signaling to promote myofiber survival, reinnervation, and remodeling, perhaps to an extreme in PD.NEW & NOTEWORTHY Despite our awareness of the impact of Parkinson's disease (PD) on motor function for over two centuries, limited attention has focused on skeletal muscle. We previously identified type I myofiber grouping, a novel indicator of muscle dysfunction in PD, presumably a result of heightened rates of denervation/reinnervation. Using transcriptional profiling to identify networks associated with this phenotype, we provide insight into potential mechanistic roles of skeletal muscle in signaling to promote its survival in PD.

Changing views of the pathophysiology of Parkinsonism

Studies of the pathophysiology of parkinsonism (specifically akinesia and bradykinesia) have a long history and primarily model the consequences of dopamine loss in the basal ganglia on the function of the basal ganglia/thalamocortical circuit(s). Changes of firing rates of individual nodes within these circuits were originally considered central to parkinsonism. However, this view has now given way to the belief that changes in firing patterns within the basal ganglia and related nuclei are more important, including the emergence of burst discharges, greater synchrony of firing between neighboring neurons, oscillatory activity patterns, and the excessive coupling of oscillatory activities at different frequencies. Primarily focusing on studies obtained in nonhuman primates and human patients with Parkinson's disease, this review summarizes the current state of this field and highlights several emerging areas of research, including studies of the impact of the heterogeneity of external pallidal neurons on parkinsonism, the importance of extrastriatal dopamine loss, parkinsonism-associated synaptic and morphologic plasticity, and the potential role(s) of the cerebellum and brainstem in the motor dysfunction of Parkinson's disease. © 2019 International Parkinson and Movement Disorder Society.

Altered Levels of Proteins and Phosphoproteins, in the Absence of Early Causative Transcriptional Changes, Shape the Molecular Pathogenesis in the Brain of Young Presymptomatic Ki91 SCA3/MJD Mouse

Spinocerebellar ataxia type 3 (SCA3/MJD) is a polyQ neurodegenerative disease where the presymptomatic phase of pathogenesis is unknown. Therefore, we investigated the molecular network of transcriptomic and proteomic triggers in young presymptomatic SCA3/MJD brain from Ki91 knock-in mouse. We found that transcriptional dysregulations resulting from mutant ataxin-3 are not occurring in young Ki91 mice, while old Ki91 mice and also postmitotic patient SCA3 neurons demonstrate the late transcriptomic changes. Unlike the lack of early mRNA changes, we have identified numerous early changes of total proteins and phosphoproteins in 2-month-old Ki91 mouse cortex and cerebellum. We discovered the network of processes in presymptomatic SCA3 with three main groups of disturbed processes comprising altered proteins: (I) modulation of protein levels and DNA damage (Pabpc1, Ddb1, Nedd8), (II) formation of neuronal cellular structures (Tubb3, Nefh, p-Tau), and (III) neuronal function affected by processes following perturbed cytoskeletal formation (Mt-Co3, Stx1b, p-Syn1). Phosphoproteins downregulate in the young Ki91 mouse brain and their phosphosites are associated with kinases that interact with ATXN3 such as casein kinase, Camk2, and kinases controlled by another Atxn3 interactor p21 such as Gsk3, Pka, and Cdk kinases. We conclude that the onset of SCA3 pathology occurs without altered transcript level and is characterized by changed levels of proteins responsible for termination of translation, DNA damage, spliceosome, and protein phosphorylation. This disturbs global cellular processes such as cytoskeleton and transport of vesicles and mitochondria along axons causing energy deficit and neurodegeneration also manifesting in an altered level of transcripts at later ages.

Stimulation over the cerebellum with a regular figure-of-eight coil induces reduced motor cortex inhibition in patients with progressive supranuclear palsy

OBJECTIVE

To determine whether motor cortex inhibition by stimulation over the cerebellum with a figure-of eight coil (MISC8) may be reduced in patients with Progressive Supranuclear Palsy (PSP).

METHODS

Paired pulse TMS was used to evaluate MISC8, in patients with different forms of parkinsonism and dementia. The primary outcome measures were sensitivity and specificity of motor cortex inhibition, derived from receiver operator curve analysis, in discriminating PSP from other neurodegenerative disorders.

RESULTS

A total of 150 participants met inclusion criteria. According to clinical criteria, the study population included 19 PSP, 26 Parkinson's disease, 25 dementia with Lewy bodies, 15 corticobasal syndrome, 25 frontotemporal dementia and 15 Alzheimer's disease patients, and 25 healthy controls. PSP patients were characterized by a specific impairment of MISC8 (0.99 ± 0.08) compared to the healthy control group and to other neurodegenerative disorders (mean range = 0.63-0.80, all p-values<0.001). Using the best cut-off index, MISC8 differentiated PSP from other diagnoses with an overall sensitivity of 100%, a specificity of 94%, and an accuracy of 97%.

CONCLUSIONS

TMS is a non-invasive procedure which reliably distinguishes PSP from other neurodegenerative disorders. MISC8 could represent a useful additional diagnostic tool to be used in clinical practice.

Does cerebellar non-invasive brain stimulation affect corticospinal excitability in healthy individuals? A systematic review of literature and meta-analysis

Numerous studies have indicated that non-invasive brain stimulation (NIBS) of the cerebellum could modulate corticospinal excitability (CSE) in young healthy individuals. However, there is no systematic review and meta-analysis that clarifies the effects of cerebellar NIBS on CSE. The aim of this study was to provide a meta-analytic summary of the effects of cerebellar NIBS on CSE. Seven search engines were used to identify any trial evaluating CSE before and after one session of cerebellar NIBS in healthy individuals up to June 2018. Twenty-six studies investigating the corticospinal responses following cerebellar NIBS were included. Meta-analysis was used to pool the findings from included studies. Effects were expressed as mean differences (MD) and the standard deviation (SD). Risk of bias was assessed with the Cochrane tool. Meta-analysis found that paired associative stimulation (PAS) with 2 ms interval, a combination of PAS with 21.5 ms interval and anodal transcranial direct current stimulation, and repetitive transcranial magnetic stimulation with a frequency of < 5 Hz increase CSE (P _PAS2 < 0.00001, P _{PAS21.5 +a-tDCS} = 0.02, P _rTMS = 0.04). However, continuous theta burst stimulation, a combination of PAS with 25 ms interval and anodal transcranial direct current stimulation, and PAS with a 6 ms interval decreased CSE (P _PAS6 < 0.00001, P _cTBS < 0.00001, P _{PAS25 +a-tDCS} = 0.003). The results of this review show that cerebellar NIBS techniques are a promising tool for increasing CSE.

Dystonia as a network disorder: a concept in evolution

PURPOSE OF REVIEW

This survey takes into consideration the most recent advances in both human degenerative ataxias, disorders with a well established cerebellar origin, and discoveries from dystonia rodent models aimed at discussing the pathogenesis of dystonia.

RECENT FINDINGS

One common recurrent term that emerges when describing dystonia is heterogeneity. Indeed, dystonia encompasses a wide group of 'hyperkinetic' movement disorders, with heterogeneous causes, classification, anatomical and physiological substrates. In addition, the clinical heterogeneity of age at onset, symptom distribution and appearance of non-motor symptoms has supported the concept of dystonia as 'network' disorder. Pathophysiological alterations are thought to arise from dysfunction at cortico-thalamic-basal ganglia level, whereas, more recently, a role for cerebellar pathways emerged. Results from human and animal studies thus fuel the evolving concept of the network disorder.

SUMMARY

Current evidence suggests the involvement of multiple brain regions and cellular mechanisms, as part of the neural dysfunction observed at system level in dystonia.

Transcranial magnetic stimulation in hereditary ataxias: Diagnostic utility, pathophysiological insight and treatment

Transcranial magnetic stimulation (TMS) is a valuable technique to assess and modulate human brain function in normal and pathological conditions. This critical review surveys the contributions of TMS to the diagnosis, insight into pathophysiology and treatment of genetically confirmed hereditary ataxias, a heterogeneous group of neurodegenerative disorders that can affect motor cortex and the corticospinal tract. Most studies were conducted on small sample sizes and focused on diagnostic approaches. The available data demonstrate early involvement of the corticospinal tract and motor cortex circuitry, and support the possible efficacy of cerebellar repetitive TMS (rTMS) as therapeutic approach. Further TMS-based studies are warranted, to establish biomarkers for early diagnosis and disease monitoring, explore the involvement of the cerebello-dentato-thalamo-cortical projection, study the effects of rTMS-induced plasticity, and utilize rTMS for treatment.

Assessing cerebellar brain inhibition (CBI) via transcranial magnetic stimulation (TMS): A systematic review

The inhibitory tone that the cerebellum exerts on the primary motor cortex (M1) is known as cerebellar brain inhibition (CBI). Studies show CBI to be relevant to several motor functions, including adaptive motor learning and muscle control. CBI can be assessed noninvasively via transcranial magnetic stimulation (TMS) using a double-coil protocol. Variability in parameter choice and controversy surrounding the protocol's ability to isolate the cerebellothalamocortical pathway casts doubt over its validity in neuroscience research. This justifies a systematic review of both the protocol, and its application. The following review examines studies using the double-coil protocol to assess CBI in healthy adults. Parameters and CBI in relation to task-based studies, other non-invasive protocols, over different muscles, and in clinical samples are reviewed. Of the 1398 studies identified, 24 met selection criteria. It was found that methodological design and selection of parameters in several studies may have reduced the validity of outcomes. Further systematic testing of CBI protocols is warranted, both from a parameter and task-based perspective.