Modulating Frontal Networks' Timing-Dependent-Like Plasticity With Paired Associative Stimulation Protocols: Recent Advances and Future Perspectives

Visuomotor paired associative stimulation enhances corticospinal excitability in post-stroke patients with upper-limb hemiparesis

We assess the effectiveness of a visuomotor paired associative stimulation (vm-PAS) protocol targeting the Action Observation Network (AON) in chronic post-stroke patients with upper-limb mild hemiparesis. Vm-PAS consisted of hand-grasping action observation stimuli repeatedly paired with transcranial magnetic stimulation (TMS) pulses over the ipsilesional primary motor cortex (M1). Fifteen post-stroke patients underwent a session of the vm-PAS and, as a control, of the standard excitatory PAS (M1-PAS), during which slow-rate electrical stimulation of the paretic limb was paired with M1-TMS. Before and after each PAS, we assessed corticospinal excitability (CSE), short-interval intracortical inhibition (SICI), and paretic wrist's voluntary movements. The two protocols induce distinct muscle-specific CSE enhancements: vm-PAS increases motor-evoked potentials (MEPs) recorded from the paretic first dorsal interosseous muscle. Conversely, M1-PAS increases MEPs recorded from the electrically stimulated extensor carpi radialis muscle. Vm-PAS efficacy correlates with hemiparesis chronicity: the higher the time elapsed since the stroke, the greater vm-PAS effects on CSE. Neither protocol affected SICI or wrist movements. Our results suggest that vm-PAS leads to muscle-specific enhancements of CSE in post-stroke patients, highlighting its potential for modulating M1 excitability after stroke. These findings show the efficacy of a cross-modal PAS protocol targeting the AON in an injured motor system.

Stimulation Parameters Recruit Distinct Cortico-Cortical Pathways: Insights from Microstate Analysis on TMS-Evoked Potentials

Transcranial magnetic stimulation (TMS)-evoked potentials (TEPs) represent an innovative measure for examining brain connectivity and developing biomarkers of psychiatric conditions. Minimizing TEP variability across studies and participants, which may stem from methodological choices, is therefore vital. By combining classic peak analysis and microstate investigation, we tested how TMS pulse waveform and current direction may affect cortico-cortical circuit engagement when targeting the primary motor cortex (M1). We aim to disentangle whether changing these parameters affects the degree of activation of the same neural circuitry or may lead to changes in the pathways through which the induced activation spreads. Thirty-two healthy participants underwent a TMS-EEG experiment in which the pulse waveform (monophasic, biphasic) and current direction (posterior-anterior, anterior-posterior, latero-medial) were manipulated. We assessed the latency and amplitude of M1-TEP components and employed microstate analyses to test differences in topographies. Results revealed that TMS parameters strongly influenced M1-TEP components' amplitude but had a weaker role over their latencies. Microstate analysis showed that the current direction in monophasic stimulations changed the pattern of evoked microstates at the early TEP latencies, as well as their duration and global field power. This study shows that the current direction of monophasic pulses may modulate cortical sources contributing to TEP signals, activating neural populations and cortico-cortical paths more selectively. Biphasic stimulation reduces the variability associated with current direction and may be better suited when TMS targeting is blind to anatomical information.

Tracking Changes in Corticospinal Excitability During Visuomotor Paired Associative Stimulation to Predict Motor Resonance Rewriting

Background/Objectives. Mirror properties of the action observation network (AON) can be modulated through Hebbian-like associative plasticity using paired associative stimulation (PAS). We recently introduced a visuomotor protocol (mirror-PAS, m-PAS) that pairs transcranial magnetic stimulation (TMS) over the primary motor cortex (M1) with visual stimuli of ipsilateral (to TMS) movements, leading to atypical corticospinal excitability (CSE) facilitation (i.e., motor resonance) during PAS-conditioned action observation. While m-PAS aftereffects are robust, little is known about markers of associative plasticity during its administration and their predictive value for subsequent motor resonance rewriting. The present study aims to fill this gap by investigating CSE modulations during m-PAS and their relationship with the protocol's aftereffects. Methods. We analyzed CSE dynamics in 81 healthy participants undergoing the m-PAS before and after passively observing left- or right-hand index finger movements. Here, typical and PAS-conditioned motor resonance was assessed with TMS over the right M1. We examined CSE changes during the m-PAS and used linear regression models to explore their relationship with motor resonance modulations. Results. m-PAS transiently reshaped both typical and PAS-induced motor resonance. Importantly, we found a gradual increase in CSE during m-PAS, which predicted the loss of typical motor resonance but not the emergence of atypical responses after the protocol's administration. Conclusions. Our results suggest that the motor resonance reshaping induced by the m-PAS is not entirely predictable by CSE online modulations. Likely, this rewriting is the product of a large-scale reorganization of the AON rather than a phenomenon restricted to the PAS-stimulated motor cortex. This study underlines that monitoring CSE during non-invasive brain stimulation protocols could provide valuable insight into some but not all plastic outcomes.

Investigating the effects of cortico-cortical paired associative stimulation in the human brain: A systematic review and meta-analysis

Recent decades have witnessed a rapid development of novel neuromodulation techniques that allow direct manipulation of cortical pathways in the human brain. These techniques, known as cortico-cortical paired stimulation (ccPAS), apply magnetic stimulation over two cortical regions altering interregional connectivity. This review evaluates ccPAS's effectiveness to induce plastic changes in cortical pathways in the healthy brain. A systematic database search identified 41 studies investigating the effect of ccPAS on neurophysiological or behavioural measures, and a subsequent multilevel meta-analysis focused on the standardized mean differences to assess ccPAS's efficacy. Most studies report significant neurophysiological and behavioural changes from ccPAS interventions across several brain networks, consistently showing medium effect sizes. Moderator analyses revealed limited influence of experimental manipulations on effect sizes. The multivariate approach and lack of small-study bias suggest reliable effect estimates. ccPAS is a promising tool to manipulate neuroplasticity in cortical pathways, showing reliable effects on brain cortical networks. Important areas for further research on the influence of experimental procedures and the potential of ccPAS for clinical interventions are highlighted.

The effects of rTMS on motor recovery after stroke: a systematic review of fMRI studies

Repetitive transcranial magnetic stimulation (rTMS) has been widely used in motor rehabilitation after stroke, and functional magnetic resonance imaging (fMRI) has been used to investigate the neural mechanisms of motor recovery during stroke therapy. However, there is no review on the mechanism of rTMS intervention for motor recovery after stroke based on fMRI explicitly. We aim to reveal and summarize the neural mechanism of the effects of rTMS on motor function after stroke as measured by fMRI. We carefully performed a literature search using PubMed, EMBASE, Web of Science, and Cochrane Library databases from their respective inceptions to November 2022 to identify any relevant randomized controlled trials. Researchers independently screened the literature, extracted data, and qualitatively described the included studies. Eleven studies with a total of 420 poststroke patients were finally included in this systematic review. A total of 338 of those participants received fMRI examinations before and after rTMS intervention. Five studies reported the effects of rTMS on activation of brain regions, and four studies reported results related to brain functional connectivity (FC). Additionally, five studies analyzed the correlation between fMRI and motor evaluation. The neural mechanism of rTMS in improving motor function after stroke may be the activation and FCs of motor-related brain areas, including enhancement of the activation of motor-related brain areas in the affected hemisphere, inhibition of the activation of motor-related brain areas in the unaffected hemisphere, and changing the FCs of intra-hemispheric and inter-hemispheric motor networks.

Influence of frontal-to-parietal connectivity in pseudoneglect: A cortico-cortical paired associative stimulation study

Pseudoneglect is a set of visuospatial biases that entails a behavioral advantage for stimuli appearing in the left hemifield compared to the right one. Although right hemisphere dominance for visuospatial processing has been invoked to explain this phenomenon, its neurophysiological mechanisms are still debated, and the role of intra- and inter-hemispheric connectivity is yet to be defined. The present study explored the possibility of modulating pseudoneglect in healthy participants through a cortico-cortical paired associative stimulation protocol (ccPAS): a non-invasive brain stimulation protocol that manipulates the interplay between brain regions through the repeated, time-locked coupling of two transcranial magnetic stimulation (TMS) pulses. In the first experiment, healthy participants underwent a frontal-to-parietal (FP) and a parietal-to-frontal (PF) ccPAS. In the FP protocol, the first TMS pulse targeted the right frontal eye field (FEF), and the second pulse the right inferior parietal lobule (IPL), two critical areas for visuospatial and attentional processing. In the PF condition, the order of the pulses was reversed. In both protocols, the inter-stimulus interval (ISI) was 10 ms. Before and after stimulation, pseudoneglect was assessed with a landmark task and a manual line bisection task. A second experiment controlled for ccPAS timing dependency by testing FP-ccPAS with a longer ISI of 100 ms. Results showed that after administering the FP-ccPAS with the ISI of 10 ms, participants' leftward bias in the landmark task increased significantly, with no effects in the manual line bisection task. The other two protocols tested were ineffective. Our findings showed that ccPAS could be used to modulate pseudoneglect by exploiting frontal-to-parietal connectivity, possibly through increased top-down attentional control. FP-ccPAS could represent a promising tool to investigate connectivity properties within visuospatial and attentional networks in the healthy and as a potential rehabilitation protocol in patients suffering from severe visuospatial pathologies.

Can we manipulate brain connectivity? A systematic review of cortico-cortical paired associative stimulation effects

OBJECTIVE

Cortico-cortical paired associative stimulation (ccPAS) is a form of dual-site transcranial magnetic stimulation (TMS) entailing a series of single-TMS pulses paired at specific interstimulus intervals (ISI) delivered to distant cortical areas. The goal of this article is to systematically review its efficacy in inducing plasticity in humans focusing on stimulation parameters and hypotheses of underlying neurophysiology.

METHODS

A systematic review of the literature from 2009-2023 was undertaken to identify all articles utilizing ccPAS to study brain plasticity and connectivity. Six electronic databases were searched and included.

RESULTS

32 studies were identified. The studies targeted connections within the same hemisphere or between hemispheres. 28 ccPAS studies were in healthy participants, 1 study in schizophrenia, and 1 in Alzheimer's disease (AD) patients. 2 additional studies used cortico-cortical repetitive paired associative stimulation (cc-rPAS) in generalized anxiety disorder (GAD) patients. Outcome measures include electromyography (EMG), behavioral measures, electroencephalography (EEG), and functional magnetic resonance imaging (fMRI). ccPAS seems to be able to modulate brain connectivity depending on the ISI.

CONCLUSIONS

ccPAS can be used to modulate corticospinal excitability, brain activity, and behavior. Although the stimulation parameters used across studies reviewed in this paper are varied, ccPAS is a promising approach for basic research and potential clinical applications.

SIGNIFICANCE

Recent advances in neuroscience have caused a shift of interest from the study of single areas to a more complex approach focusing on networks of areas that orchestrate brain activity. Consequently, the TMS community is also witnessing a change, with a growing interest in targeting multiple brain areas rather than a single locus, as evidenced by an increasing number of papers using ccPAS. In light of this new enthusiasm for brain connectivity, this review summarizes existing literature and stimulation parameters that have proven effective in changing electrophysiological, behavioral, or neuroimaging-derived measures.

Intraclass Correlation in Paired Associative Stimulation and Metaplasticity

Paired associative stimulation (PAS) is a widely used noninvasive brain stimulation protocol to assess neural plasticity. Its reproducibility, however, has been rarely tested and with mixed results. With two consecutive studies, we aimed to provide further tests and a more systematic assessment of PAS reproducibility. We measured intraclass correlation coefficients (ICCs)-a widely used tool to assess whether groups of measurements resemble each other-in two PAS studies on healthy volunteers. The first study included five PAS sessions recording 10 MEPS every 10 min for an hour post-PAS. The second study included two PAS sessions recording 50 MEPS at 20 and 50 min post-PAS, based on analyses from the first study. In both studies PAS sessions were spaced one week apart. Within sessions ICC was fair to excellent for both studies, yet between sessions ICC was poor for both studies. We suggest that long term meta-plasticity effects (longer than one week) may interfere with between sessions reproducibility.

Paired associative stimulations: Novel tools for interacting with sensory and motor cortical plasticity

In the early 2000s, a novel non-invasive brain stimulation protocol, the paired associative stimulation (PAS), was introduced, allowing to induce and investigate Hebbian associative plasticity within the humans' motor system, with patterns resembling spike-timing-dependent plasticity properties found in cellular models. Since this evidence, PAS efficacy has been proved in healthy, and to a lesser extent, in clinical populations. Recently, novel 'modified' protocols targeting sensorimotor and crossmodal networks appeared in the literature. In the present work, we have reviewed recent advances using these 'modified' PAS protocols targeting sensory and motor cortical networks. To better categorize them, we propose a novel classification according to the nature of the peripheral and cortical stimulations (i.e., within-system, cross-systems, and cortico-cortical PAS). For each protocol of the categories mentioned above, we describe and discuss their main features, how they have been used to study and promote brain plasticity, and their advantages and disadvantages. Overall, current evidence suggests that these novel non-invasive brain stimulation protocols represent very promising tools to study the plastic properties of humans' sensorimotor and crossmodal networks, both in the healthy and in the damaged central nervous system.