1
|
De Doncker W, Kuppuswamy A. Lesioned hemisphere-specific phenotypes of post-stroke fatigue emerge from motor and mood characteristics in chronic stroke. Eur J Neurol 2024; 31:e16170. [PMID: 38069662 DOI: 10.1111/ene.16170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/03/2023] [Accepted: 11/14/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND PURPOSE Post-stroke fatigue commonly presents alongside several comorbidities. The interaction between comorbidities and their relationship to fatigue is not known. In this study, we focus on physical and mood comorbidities, alongside lesion characteristics. We predict the emergence of distinct fatigue phenotypes with distinguishable physical and mood characteristics. METHODS In this cross-sectional observational study, in 94 first time, non-depressed, moderate to minimally impaired chronic stroke survivors, the relationship between measures of motor function (grip strength, nine-hole peg test time), motor cortical excitability (resting motor threshold), Hospital Anxiety and Depression Scale and Fatigue Severity Scale-7 (FSS-7) scores, age, gender and side of stroke was established using Spearman's rank correlation. Mood and motor variables were then entered into a k-means clustering algorithm to identify the number of unique clusters, if any. Post hoc pairwise comparisons followed by corrections for multiple comparisons were performed to characterize differences among clusters in the variables included in k-means clustering. RESULTS Clustering analysis revealed a four-cluster model to be the best model (average silhouette score of 0.311). There was no significant difference in FSS-7 scores among the four high-fatigue clusters. Two clusters consisted of only left-hemisphere strokes, and the remaining two were exclusively right-hemisphere strokes. Factors that differentiated hemisphere-specific clusters were the level of depressive symptoms and anxiety. Motor characteristics distinguished the low-depressive left-hemisphere from the right-hemisphere clusters. CONCLUSION The significant differences in side of stroke and the differential relationship between mood and motor function in the four clusters reveal the heterogenous nature of post-stroke fatigue, which is amenable to categorization. Such categorization is critical to an understanding of the interactions between post-stroke fatigue and its presenting comorbid deficits, with significant implications for the development of context-/category-specific interventions.
Collapse
Affiliation(s)
- William De Doncker
- Department of Clinical and Movement Neuroscience, Institute of Neurology, University College London, London, UK
| | - Annapoorna Kuppuswamy
- Department of Clinical and Movement Neuroscience, Institute of Neurology, University College London, London, UK
- Department of Biomedical Sciences, University of Leeds, Leeds, UK
| |
Collapse
|
2
|
Liang S, Wang W, Yu F, Pan L, Xu D, Hu R, Tian S, Xiang J, Zhu Y. Repetitive peripheral magnetic stimulation combined with transcranial magnetic stimulation in rehabilitation of upper extremity hemiparesis following stroke: a pilot study. J Rehabil Med 2024; 56:jrm19449. [PMID: 38298134 PMCID: PMC10847975 DOI: 10.2340/jrm.v56.19449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/20/2023] [Indexed: 02/02/2024] Open
Abstract
OBJECTIVE To investigate the effect of combined repetitive peripheral magnetic stimulation and transcranial magnetic stimulation on upper extremity function in subacute stroke patients. DESIGN Pilot study. SUBJECTS Subacute stroke patients. METHODS Included patients were randomized into 3 groups: a central-associated peripheral stimulation (CPS) group, a central-stimulation-only (CS) group, and a control (C) group. The CPS group underwent a new paired associative stimulation (combined repetitive peripheral magnetic stimulation and transcranial magnetic stimulation), the CS group underwent repetitive transcranial magnetic stimulation, and the C group underwent sham stimulation. All 3 groups received physiotherapy after the stimulation or sham stimulation. The treatment comprised 20 once-daily sessions. Primary outcome was the Fugl-Meyer Assessment Upper Extremity (FMA-UE) score, and secondary outcomes were the Barthel Index and Comprehensive Functional Assessment scores, and neurophysiological assessments were mainly short-interval intracortical inhibition. A 3-group (CPS, CS, C) × 2-time (before, after intervention) repeated measures analysis of variance was conducted to determine whether changes in scores were significantly different between the 3 groups. RESULTS A total of 45 patients were included in the analysis. Between-group comparisons on the FMA-UE demonstrated a significant improvement (group × time interaction, F2,42 = 4.86; p = 0.013; C vs CS, p = 0.020; C vs CPS, p = 0.016; CS vs CPS, p = 0.955). Correlation analysis did not find any substantial positive correlation between changes in FMA-UE and short-interval intracortical inhibition variables (C, r = -0.196, p = 0.483; CS, r = -0.169, p = 0.546; CPS, r = -0.424, p = 0.115). CONCLUSION This study suggests that the real-stimulus (CS and CPS) groups had better outcomes than the control (C) group. In addition, the CPS group showed a better trend in clinical and neurophysiological assessments compared with the CS group.
Collapse
Affiliation(s)
- Sijie Liang
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China; Department of Rehabilitation Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Weining Wang
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Fengyun Yu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Li Pan
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Dongyan Xu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Ruiping Hu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Shan Tian
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jie Xiang
- Department of Rehabilitation Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Yulian Zhu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China.
| |
Collapse
|
3
|
Herr T, Kleger P, Strauss S, Szeska C, Khalil N, Badran BW, Weymar M, Grothe M. Effect of non-invasive transcutaneous auricular vagus nerve stimulation on cerebral motor excitability-Study protocol for a randomized, sham controlled trial. Front Neurol 2024; 14:1341898. [PMID: 38283680 PMCID: PMC10811126 DOI: 10.3389/fneur.2023.1341898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Transcutaneous auricular vagus nerve stimulation (taVNS) is becoming increasingly established in the treatment of various neurological and psychiatric diseases. However, only a few studies have focused on the overall influence of taVNS on cortical excitability in general. The planned study will investigate the effect of taVNS on the excitability of the motor cortex in young healthy subjects. The aim of the study is to gain better understand of the physiological mechanism of taVNS to contribute to new fields of application of taVNS in new areas such as the treatment of stroke or multiple sclerosis. This protocol describes a single-center, prospective, double blind, sham-controlled trial that evaluates the effect of taVNS on motor cortex excitability with a planned sample size of 30 participants. The effect of taVNS is investigated by neuronavigation and electromyography (EMG) coupled transcranial magnetic stimulation (TMS) applied before and after taVNS stimulation. The following parameters are assessed: resting motor threshold (RMT), active motor threshold (AMT), recruitment curve (RC), short intracortical inhibition (SICI), intracortical facilitation (ICF). All parameters will be assessed for taVNS on the basis of perception threshold and tolerance threshold. All investigations performed in the study were reviewed and approved by the local ethics committee of the University Medical Center Greifswald (study reference number: BB048/22). Clinical trial registration www.drks.de, number: DRKS00029937.
Collapse
Affiliation(s)
- Thorsten Herr
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Paula Kleger
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Strauss
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Christoph Szeska
- Department of Biological Psychology and Affective Science, Faculty of Human Sciences, University of Potsdam, Potsdam, Germany
| | - Nura Khalil
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Bashar W. Badran
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, United States
| | - Mathias Weymar
- Department of Biological Psychology and Affective Science, Faculty of Human Sciences, University of Potsdam, Potsdam, Germany
- Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
| | - Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| |
Collapse
|
4
|
Wang MX, Wumiti A, Zhang YW, Gao XS, Huang Z, Zhang MF, Peng ZY, Oku Y, Tang ZM. Transcutaneous cervical vagus nerve stimulation improved motor cortex excitability in healthy adults: a randomized, single-blind, self-crossover design study. Front Neurosci 2023; 17:1234033. [PMID: 37854293 PMCID: PMC10579560 DOI: 10.3389/fnins.2023.1234033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023] Open
Abstract
Purpose To investigate the effect of transcutaneous cervical vagus nerve stimulation (tcVNS) on motor cortex excitability in healthy adults. Method Twenty eight healthy subjects were assigned to receive real and sham tcVNS for 30 min. The interval between the real and sham conditions was more than 24 h, and the sequence was random. The central and peripheral motor-evoked potential (MEP) of the right first dorsal interosseous (FDI) muscle was measured by transcranial magnetic stimulation (TMS) before and after stimulation. MEP latency, MEP amplitude and rest motor threshold (rMT) were analyzed before and after stimulation. Results MEP amplitude, MEP latency and rMT had significant interaction effect between time points and conditions (p < 0.05). After real stimulation, the MEP amplitude was significantly increased (p < 0.001). MEP latency (p < 0.001) and rMT (p = 0.006) was decreased than that of baseline. The MEP amplitude on real condition was higher than that of sham stimulation after stimulation (p = 0.027). The latency after the real stimulation was significantly shorter than that after sham stimulation (p = 0.005). No significantly difference was found in rMT after stimulation between real and sham conditions (p > 0.05). Conclusion tcVNS could improve motor cortex excitability in healthy adults.
Collapse
Affiliation(s)
- Meng-Xin Wang
- Department of Rehabilitation Medicine, Yuedong Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Meizhou, China
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Aihaiti Wumiti
- Department of Rehabilitation Medicine, Yuedong Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Meizhou, China
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yao-Wen Zhang
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xue-Sheng Gao
- Rehabilitation Medicine Department, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Zi Huang
- Department of Rehabilitation Medicine, Yuedong Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Meizhou, China
| | - Meng-Fei Zhang
- Department of Rehabilitation Medicine, Yuedong Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Meizhou, China
| | - Zhi-Yong Peng
- Department of Rehabilitation Medicine, Yuedong Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Meizhou, China
| | - Yoshitaka Oku
- Department of Physiology, Hyogo Medical University, Hyogo, Japan
| | - Zhi-Ming Tang
- Department of Rehabilitation Medicine, Yuedong Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Meizhou, China
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
5
|
Giovannelli F, Borgheresi A, Lucidi G, Squitieri M, Gavazzi G, Suppa A, Berardelli A, Viggiano MP, Cincotta M. Language-related motor facilitation in Italian Sign Language signers. Cereb Cortex 2023:6988100. [PMID: 36646456 DOI: 10.1093/cercor/bhac536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/23/2022] [Accepted: 12/24/2022] [Indexed: 01/18/2023] Open
Abstract
Linguistic tasks facilitate corticospinal excitability as revealed by increased motor evoked potential (MEP) induced by transcranial magnetic stimulation (TMS) in the dominant hand. This modulation of the primary motor cortex (M1) excitability may reflect the relationship between speech and gestures. It is conceivable that in healthy individuals who use a sign language this cortical excitability modulation could be rearranged. The aim of this study was to evaluate the effect of spoken language tasks on M1 excitability in a group of hearing signers. Ten hearing Italian Sign Language (LIS) signers and 16 non-signer healthy controls participated. Single-pulse TMS was applied to either M1 hand area at the baseline and during different tasks: (i) reading aloud, (ii) silent reading, (iii) oral movements, (iv) syllabic phonation and (v) looking at meaningless non-letter strings. Overall, M1 excitability during the linguistic and non-linguistic tasks was higher in LIS group compared to the control group. In LIS group, MEPs were significantly larger during reading aloud, silent reading and non-verbal oral movements, regardless the hemisphere. These results suggest that in hearing signers there is a different modulation of the functional connectivity between the speech-related brain network and the motor system.
Collapse
Affiliation(s)
- Fabio Giovannelli
- Department of Neuroscience, Psychology, Drug Research and Child's Health (NEUROFARBA), Section of Psychology, University of Florence, Florence 50135, Italy
| | - Alessandra Borgheresi
- Unit of Neurology of Florence, Central Tuscany Local Health Authority, Florence 50143, Italy
| | - Giulia Lucidi
- Unit of Neurology of Florence, Central Tuscany Local Health Authority, Florence 50143, Italy
| | - Martina Squitieri
- Unit of Neurology of Florence, Central Tuscany Local Health Authority, Florence 50143, Italy
| | - Gioele Gavazzi
- Department of Neuroscience, Psychology, Drug Research and Child's Health (NEUROFARBA), Section of Psychology, University of Florence, Florence 50135, Italy
| | - Antonio Suppa
- Department of Human Neurosciences, Sapienza University of Rome, Rome 00185, Italy.,IRCCS Neuromed, Pozzilli (IS) 86077, Italy
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza University of Rome, Rome 00185, Italy.,IRCCS Neuromed, Pozzilli (IS) 86077, Italy
| | - Maria Pia Viggiano
- Department of Neuroscience, Psychology, Drug Research and Child's Health (NEUROFARBA), Section of Psychology, University of Florence, Florence 50135, Italy
| | - Massimo Cincotta
- Unit of Neurology of Florence, Central Tuscany Local Health Authority, Florence 50143, Italy
| |
Collapse
|
6
|
Ma R, Xia X, Zhang W, Lu Z, Wu Q, Cui J, Song H, Fan C, Chen X, Zha R, Wei J, Ji GJ, Wang X, Qiu B, Zhang X. High Gamma and Beta Temporal Interference Stimulation in the Human Motor Cortex Improves Motor Functions. Front Neurosci 2022; 15:800436. [PMID: 35046771 PMCID: PMC8761631 DOI: 10.3389/fnins.2021.800436] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/29/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Temporal interference (TI) stimulation is a new technique of non-invasive brain stimulation. Envelope-modulated waveforms with two high-frequency carriers can activate neurons in target brain regions without stimulating the overlying cortex, which has been validated in mouse brains. However, whether TI stimulation can work on the human brain has not been elucidated. Objective: To assess the effectiveness of the envelope-modulated waveform of TI stimulation on the human primary motor cortex (M1). Methods: Participants attended three sessions of 30-min TI stimulation during a random reaction time task (RRTT) or a serial reaction time task (SRTT). Motor cortex excitability was measured before and after TI stimulation. Results: In the RRTT experiment, only 70 Hz TI stimulation had a promoting effect on the reaction time (RT) performance and excitability of the motor cortex compared to sham stimulation. Meanwhile, compared with the sham condition, only 20 Hz TI stimulation significantly facilitated motor learning in the SRTT experiment, which was significantly positively correlated with the increase in motor evoked potential. Conclusion: These results indicate that the envelope-modulated waveform of TI stimulation has a significant promoting effect on human motor functions, experimentally suggesting the effectiveness of TI stimulation in humans for the first time and paving the way for further explorations.
Collapse
Affiliation(s)
- Ru Ma
- Hefei National Laboratory for Physical Sciences at the Microscale, Division of Life Science and Medicine, Department of Radiology, The First Affiliated Hospital of USTC, School of Life Science, University of Science and Technology of China, Hefei, China
| | - Xinzhao Xia
- Centers for Biomedical Engineering, School of Information Science and Technology, University of Science and Technology of China, Hefei, China
| | - Wei Zhang
- Hefei National Laboratory for Physical Sciences at the Microscale, Division of Life Science and Medicine, Department of Radiology, The First Affiliated Hospital of USTC, School of Life Science, University of Science and Technology of China, Hefei, China
| | - Zhuo Lu
- Centers for Biomedical Engineering, School of Information Science and Technology, University of Science and Technology of China, Hefei, China
| | - Qianying Wu
- Hefei National Laboratory for Physical Sciences at the Microscale, Division of Life Science and Medicine, Department of Radiology, The First Affiliated Hospital of USTC, School of Life Science, University of Science and Technology of China, Hefei, China.,Division of the Humanities and Social Sciences, California Institute of Technology, Pasadena, CA, United States
| | - Jiangtian Cui
- Centers for Biomedical Engineering, School of Information Science and Technology, University of Science and Technology of China, Hefei, China.,School of Optometry and Vision Sciences, Cardiff University, Cardiff, United Kingdom
| | - Hongwen Song
- Hefei National Laboratory for Physical Sciences at the Microscale, Division of Life Science and Medicine, Department of Radiology, The First Affiliated Hospital of USTC, School of Life Science, University of Science and Technology of China, Hefei, China
| | - Chuan Fan
- Centers for Biomedical Engineering, School of Information Science and Technology, University of Science and Technology of China, Hefei, China
| | - Xueli Chen
- Hefei National Laboratory for Physical Sciences at the Microscale, Division of Life Science and Medicine, Department of Radiology, The First Affiliated Hospital of USTC, School of Life Science, University of Science and Technology of China, Hefei, China
| | - Rujing Zha
- Hefei National Laboratory for Physical Sciences at the Microscale, Division of Life Science and Medicine, Department of Radiology, The First Affiliated Hospital of USTC, School of Life Science, University of Science and Technology of China, Hefei, China
| | - Junjie Wei
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Gong-Jun Ji
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoxiao Wang
- Centers for Biomedical Engineering, School of Information Science and Technology, University of Science and Technology of China, Hefei, China
| | - Bensheng Qiu
- Centers for Biomedical Engineering, School of Information Science and Technology, University of Science and Technology of China, Hefei, China
| | - Xiaochu Zhang
- Hefei National Laboratory for Physical Sciences at the Microscale, Division of Life Science and Medicine, Department of Radiology, The First Affiliated Hospital of USTC, School of Life Science, University of Science and Technology of China, Hefei, China.,Centers for Biomedical Engineering, School of Information Science and Technology, University of Science and Technology of China, Hefei, China.,Department of Psychology, School of Humanities and Social Science, University of Science and Technology of China, Hefei, China.,Biomedical Sciences and Health Laboratory of Anhui Province, University of Science and Technology of China, Hefei, China
| |
Collapse
|
7
|
Wang L, Nitsche MA, Zschorlich VR, Liu H, Kong Z, Qi F. 20 Hz Transcranial Alternating Current Stimulation Inhibits Observation-Execution-Related Motor Cortex Excitability. J Pers Med 2021; 11:979. [PMID: 34683120 DOI: 10.3390/jpm11100979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 12/31/2022] Open
Abstract
The present study aimed to investigate the effect of transcranial alternating current stimulation (tACS) on the primary motor cortex (M1) during action observation, and subsequent action execution, on motor cortex excitability. The participants received tACS at 10 Hz or 20 Hz, or a sham stimulation over the left M1 for 10 min while they observed a video displaying a repeated button-tapping task using the right hand, and then performed an identical task with their right hand. Motor-evoked potential (MEP) amplitudes were measured before (T0) and after the action observation paired with tACS or a sham stimulation (T1), and after the performance of the action (T2). The results showed that MEPs were significantly reduced at time point T1 (p = 0.042, Cohen’s d = 0.611) and T2 (p = 0.0003, Cohen’s d = 0.852) in the 20 Hz tACS condition, in contrast with the sham stimulation. There was a significantly smaller MEP amplitude at time point T2 in the 20 Hz tACS condition, as compared to the 10 Hz tACS condition (p = 0.01, Cohen’s d = 0.622), but the MEP amplitude did not significantly change at time point T1 between the 20 Hz and 10 Hz tACS conditions (p = 0.136, Cohen’s d = 0.536). There were no significant differences at time point T1 and T2 between the 10 Hz tACS condition and the sham stimulation. We conclude that 20 Hz tACS during action observation inhibited motor cortex excitability and subsequently inhibited execution-related motor cortex excitability. The effects of tACS on task-related motor cortex excitability are frequency-dependent.
Collapse
|
8
|
Rush JL, Lepley LK, Davi S, Lepley AS. The Immediate Effects of Transcranial Direct Current Stimulation on Quadriceps Muscle Function in Individuals With a History of Anterior Cruciate Ligament Reconstruction: A Preliminary Investigation. J Sport Rehabil 2020; 29:1121-30. [PMID: 32221043 DOI: 10.1123/jsr.2019-0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/17/2019] [Accepted: 10/16/2019] [Indexed: 11/18/2022]
Abstract
CONTEXT Altered quadriceps activation is common following anterior cruciate ligament reconstruction (ACLR), and can persist for years after surgery. These neural deficits are due, in part, to chronic central nervous system alterations. Transcranial direct current stimulation (tDCS) is a noninvasive modality, that is, believed to immediately increase motor neuron activity by stimulating the primary motor cortex, making it a promising modality to use improve outcomes in the ACLR population. OBJECTIVE To determine if a single treatment of tDCS would result in increased quadriceps activity and decreased levels of self-reported pain and dysfunction during exercise. DESIGN Randomized crossover design. SETTING Controlled laboratory. PATIENTS Ten participants with a history of ACLR (5 males/5 females, 22.9 [4.23] y, 176.57 [12.01] cm, 80.87 [16.86] kg, 68.1 [39.37] mo since ACLR). INTERVENTIONS Active tDCS and Sham tDCS. MAIN OUTCOME MEASURES Percentage of maximum electromyographic data of vastus medialis and lateralis, voluntary isometric strength, percentage of voluntary activation, and self-reported pain and symptom scores were measured. The 2 × 2 repeated-measures analysis of variance by limb were performed to explain the differences between time points (pre and post) and condition (tDCS and sham). RESULTS There was a significant time main effect for quadriceps percentage of maximum electromyographic of vastus medialis (F9,1 = 11.931, P = .01) and vastus lateralis (F9,1 = 9.132, P = .01), isometric strength (F9,1 = 5.343, P = .046), and subjective scores for pain (F9,1 = 15.499, P = .04) and symptoms (F9,1 = 15.499, P = .04). Quadriceps percentage of maximum electromyographic, isometric strength, and voluntary activation showed an immediate decline from pre to post regardless of tDCS condition. Subjective scores improved slightly after each condition. CONCLUSIONS One session of active tDCS did not have an immediate effect on quadriceps activity and subjective scores of pain and symptoms. To determine if tDCS is a valid modality for this patient population, a larger scale investigation with multiple treatments of active tDCS is warranted.
Collapse
|
9
|
Giovannelli F, Rossi S, Borgheresi A, Gavazzi G, Zaccara G, Viggiano MP, Cincotta M. Effects of Music Reading on Motor Cortex Excitability in Pianists: A Transcranial Magnetic Stimulation Study. Neuroscience 2020; 437:45-53. [PMID: 32335216 DOI: 10.1016/j.neuroscience.2020.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/13/2020] [Accepted: 04/16/2020] [Indexed: 11/29/2022]
Abstract
Neurophysiological studies suggest that music reading facilitates sensorimotor cortex. The aim of this study was to evaluate (1) whether in pianists, reading notes in bass and treble clef selectively enhances right and left primary motor cortex (M1) excitability; and (2) whether reading notes played with the thumb or little finger selectively modulates the excitability of specific muscles. Twenty musicians (11 pianists, 9 non-pianists) participated. Transcranial magnetic stimulation (TMS) was applied while subjects read the bass or the treble clef of sheets music and during the observation of a blank staff (baseline). When pianists read the treble clef, the excitability of the left M1 was higher compared to that recorded in the right M1. Moreover, in the treble clef condition motor evoked potentials (MEPs) induced by TMS of the left M1 were higher when pianists read notes to be played with the 5° finger (little finger) with respect to 1° finger (thumb) notes, whereas in the bass clef condition TMS of the right M1 induced higher MEPs for 1° finger note compared to 5° finger notes. No significant modulation was observed in non-pianists. These data support the view that music reading may induce specific inter- and intra-hemispheric modulation of the motor cortex excitability.
Collapse
Affiliation(s)
- Fabio Giovannelli
- Section of Psychology - Department of Neuroscience, Psychology, Drug Research and Child's Health (NEUROFARBA), University of Florence, Firenze, Italy; Unit of Neurology of Florence, Central Tuscany Local Health Authority, Firenze, Italy
| | - Simone Rossi
- Department of Medicine, Surgery and Neuroscience, Unit of Neurology and Clinical Neurophysiology, Siena Brain Investigation and Neuromodulation Lab (Si-BIN Lab), University of Siena, Italy
| | - Alessandra Borgheresi
- Unit of Neurology of Florence, Central Tuscany Local Health Authority, Firenze, Italy
| | | | - Gaetano Zaccara
- Unit of Neurology of Florence, Central Tuscany Local Health Authority, Firenze, Italy; Regional Health Agency of Tuscany, Firenze, Italy
| | - Maria Pia Viggiano
- Section of Psychology - Department of Neuroscience, Psychology, Drug Research and Child's Health (NEUROFARBA), University of Florence, Firenze, Italy
| | - Massimo Cincotta
- Unit of Neurology of Florence, Central Tuscany Local Health Authority, Firenze, Italy.
| |
Collapse
|
10
|
Tsuboyama M, Lee Kaye H, Rotenberg A. Biomarkers Obtained by Transcranial Magnetic Stimulation of the Motor Cortex in Epilepsy. Front Integr Neurosci 2019; 13:57. [PMID: 31736722 PMCID: PMC6837164 DOI: 10.3389/fnint.2019.00057] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022] Open
Abstract
Epilepsy is associated with numerous neurodevelopmental disorders. Transcranial magnetic stimulation (TMS) of the motor cortex coupled with electromyography (EMG) enables biomarkers that provide measures of cortical excitation and inhibition that are particularly relevant to epilepsy and related disorders. The motor threshold (MT), cortical silent period (CSP), short interval intracortical inhibition (SICI), intracortical facilitation (ICF), and long interval intracortical inhibition (LICI) are among TMS-derived metrics that are modulated by antiepileptic drugs. TMS may have a practical role in optimization of antiepileptic medication regimens, as studies demonstrate dose-dependent relationships between TMS metrics and acute medication administration. A close association between seizure freedom and normalization of cortical excitability with long-term antiepileptic drug use highlights a plausible utility of TMS in measures of anti-epileptic drug efficacy. Finally, TMS-derived biomarkers distinguish patients with various epilepsies from healthy controls and thus may enable development of disorder-specific biomarkers and therapies both within and outside of the epilepsy realm.
Collapse
Affiliation(s)
- Melissa Tsuboyama
- Neuromodulation Program, Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Boston, MA, United States.,FM Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Harper Lee Kaye
- Neuromodulation Program, Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Boston, MA, United States.,FM Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Alexander Rotenberg
- Neuromodulation Program, Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Boston, MA, United States.,FM Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, United States.,Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, United States
| |
Collapse
|
11
|
Qi F, Nitsche MA, Zschorlich VR. Interaction Between Transcranial Random Noise Stimulation and Observation-Execution Matching Activity Promotes Motor Cortex Excitability. Front Neurosci 2019; 13:69. [PMID: 30792626 PMCID: PMC6374348 DOI: 10.3389/fnins.2019.00069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/23/2019] [Indexed: 12/29/2022] Open
Abstract
Pathways of the human mirror neuron system are activated during both, action observation and action execution, including lateralized activation of respective areas, as shown by observed right-or left-hand actions. Here, we investigated whether execution-dependent motor cortex excitability is affected by prior interaction between transcranial random noise stimulation (tRNS) and action observation. Sham or real tRNS (1 mA) was applied for 10-min over the left primary motor cortex during action observation. In the main experiments, participants received sham or real tRNS while they watched a video showing repeated tapping tasks, involving either the right-hand (Experiment 1, congruent action observation), or a mirror-reversed video showing the same performance (Experiment 2), followed by action execution of the right-hand. In control Experiments 1–3, participants received real tRNS while observing a perceptual sequence, watching a landscape picture, or observing the left-hand performing the action (the sequence was identical to Experiment 1), followed by action execution of the right-hand. In control Experiment 4, participants received real tRNS during congruent action observation, and then took 6-min rest. Motor-evoked potentials (MEP) were recorded before action observation, a perceptual sequence or a landscape picture, immediately after, and after action execution, or an interval of 6-min, dependent on the respective experimental condition. MEPs in the right first dorsal interosseous muscle increased significantly after real tRNS combined with congruent action observation, and after action execution compared to the sham session in Experiment 1 and control experiments. We conclude that prior interaction between real tRNS and action observation of mirror-matched movements modulates subsequent execution-dependent motor cortex excitability.
Collapse
Affiliation(s)
- Fengxue Qi
- Department of Movement Science, Faculty of Philosophy, University of Rostock, Rostock, Germany.,Department of Psychology and Neurosciences, Leibniz Research Centre for Working Environment and Human Factors, Dortmund, Germany
| | - Michael A Nitsche
- Department of Psychology and Neurosciences, Leibniz Research Centre for Working Environment and Human Factors, Dortmund, Germany.,Department of Neurology, University Medical Hospital Bergmannsheil, Bochum, Germany
| | - Volker R Zschorlich
- Department of Movement Science, Faculty of Philosophy, University of Rostock, Rostock, Germany.,Faculty of Medicine, University of Rostock, Rostock, Germany.,Department Ageing of Individuals and Society, Faculty of Interdisciplinary Research, University of Rostock, Rostock, Germany
| |
Collapse
|
12
|
Foerster ÁS, Rezaee Z, Paulus W, Nitsche MA, Dutta A. Effects of Cathode Location and the Size of Anode on Anodal Transcranial Direct Current Stimulation Over the Leg Motor Area in Healthy Humans. Front Neurosci 2018; 12:443. [PMID: 30022928 PMCID: PMC6039564 DOI: 10.3389/fnins.2018.00443] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 06/12/2018] [Indexed: 12/30/2022] Open
Abstract
Objective: Non-invasive brain stimulation such as transcranial direct current stimulation (tDCS) involves passing low currents through the brain and is a promising tool for the modulation of cortical excitability. In this study, we investigated the effects of cathode location and the size of anode for anodal tDCS of the right-leg area of the motor cortex, which is challenging due to its depth and orientation in the inter-hemispheric fissure. Methods: We first computationally investigated the effects of cathode location and the size of the anode to find the best montage for specificity of stimulation effects for the targeted leg motor area using finite element analysis (FEA). We then compared the best electrode montage found from FEA with the conventional montage (contralateral supraorbital cathode) via neurophysiological testing of both, the targeted as well as the contralateral leg motor area. Results: The conventional anodal tDCS electrode montage for leg motor cortex stimulation using a large-anode (5 cm × 7 cm, current strength 2 mA) affected the contralateral side more strongly in both the FEA and the neurophysiological testing when compared to other electrode montages. A small-anode (3.5 cm × 1 cm at 0.2 mA) with the same current density at the electrode surface and identical contralateral supraorbital cathode placement improved specificity. The best cathode location for the small-anode in terms of specificity for anodal tDCS of the right-leg motor area was T7 (10-10 EEG system). Conclusion: A small-anode (3.5 cm × 1 cm) with the same current density at the electrode surface as a large-anode (5 cm × 7 cm) resulted in similar cortical excitability alterations of the targeted leg motor cortex respresentation. In relation to the other stimulation conditions, the small-anode montage with the cathode positioned at T7 resulted in the best specificity.
Collapse
Affiliation(s)
- Águida S Foerster
- Department of Clinical Neurophysiology, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen, Göttingen, Germany.,IfADo - Leibniz Research Center for Working Environment and Human Factors, Dortmund, Germany
| | - Zeynab Rezaee
- Department of Biomedical Engineering, University at Buffalo, The State University of New York (SUNY), Buffalo, NY, United States
| | - Walter Paulus
- Department of Clinical Neurophysiology, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen, Göttingen, Germany
| | - Michael A Nitsche
- IfADo - Leibniz Research Center for Working Environment and Human Factors, Dortmund, Germany.,Department of Neurology, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Anirban Dutta
- Department of Biomedical Engineering, University at Buffalo, The State University of New York (SUNY), Buffalo, NY, United States
| |
Collapse
|
13
|
Chen M, Summers RLS, Goding GS, Samargia S, Ludlow CL, Prudente CN, Kimberley TJ. Evaluation of the Cortical Silent Period of the Laryngeal Motor Cortex in Healthy Individuals. Front Neurosci 2017; 11:88. [PMID: 28326007 PMCID: PMC5339278 DOI: 10.3389/fnins.2017.00088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/10/2017] [Indexed: 11/13/2022] Open
Abstract
Objective: This work aimed to evaluate the cortical silent period (cSP) of the laryngeal motor cortex (LMC) using the bilateral thyroarytenoid (TA) muscles with transcranial magnetic stimulation (TMS). Methods: In 11 healthy participants, fine-wire electromyography (EMG) was used to record bilateral TA muscle responses to single pulse TMS delivered to the LMC in both hemispheres. Peripheral responses to stimulation over the mastoid, where the vagus nerve exits the skull, were collected to verify the central origin of the cortical stimulation responses by comparing the latencies. Results: The cSP duration ranged from 41.7 to 66.4 ms. The peripherally evoked motor-evoked potential (MEP) peak occurred 5–9 ms earlier than the cortical responses (for both sides of TAs: p < 0.0001) with no silent period. The right TA MEP latencies were earlier than the left TA responses for both peripheral and cortical measures (p ≤ 0.0001). Conclusion: These findings demonstrate the feasibility of measuring cSP of LMC based on intrinsic laryngeal muscles responses during vocalization in healthy volunteers. Significance: The technique could be used to study the pathophysiology of neurological disorders that affect TA muscles, such as spasmodic dysphonia. Further, the methodology has application to other muscles of the head and neck not accessible using surface electrodes.
Collapse
Affiliation(s)
- Mo Chen
- Divisions of Physical Therapy and Rehabilitation Science, Department of Rehabilitation Medicine, School of Medicine, University of Minnesota Minneapolis, MN, USA
| | - Rebekah L S Summers
- Divisions of Physical Therapy and Rehabilitation Science, Department of Rehabilitation Medicine, School of Medicine, University of Minnesota Minneapolis, MN, USA
| | - George S Goding
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota Minneapolis, MN, USA
| | - Sharyl Samargia
- Department of Communication Sciences and Disorders, University of Wisconsin River Falls Campus River Falls, WI, USA
| | - Christy L Ludlow
- Department of Communication Sciences and Disorders, James Madison University Harrisonburg, VA, USA
| | - Cecília N Prudente
- Divisions of Physical Therapy and Rehabilitation Science, Department of Rehabilitation Medicine, School of Medicine, University of Minnesota Minneapolis, MN, USA
| | - Teresa J Kimberley
- Divisions of Physical Therapy and Rehabilitation Science, Department of Rehabilitation Medicine, School of Medicine, University of Minnesota Minneapolis, MN, USA
| |
Collapse
|
14
|
Parkkonen E, Laaksonen K, Piitulainen H, Pekkola J, Parkkonen L, Tatlisumak T, Forss N. Strength of ~20-Hz Rebound and Motor Recovery After Stroke. Neurorehabil Neural Repair 2017; 31:475-486. [PMID: 28164736 DOI: 10.1177/1545968316688795] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke is a major cause of disability worldwide, and effective rehabilitation is crucial to regain skills for independent living. Recently, novel therapeutic approaches manipulating the excitatory-inhibitory balance of the motor cortex have been introduced to boost recovery after stroke. However, stroke-induced neurophysiological changes of the motor cortex may vary despite of similar clinical symptoms. Therefore, better understanding of excitability changes after stroke is essential when developing and targeting novel therapeutic approaches. OBJECTIVE AND METHODS We identified recovery-related alterations in motor cortex excitability after stroke using magnetoencephalography. Dynamics (suppression and rebound) of the ~20-Hz motor cortex rhythm were monitored during passive movement of the index finger in 23 stroke patients with upper limb paresis at acute phase, 1 month, and 1 year after stroke. RESULTS After stroke, the strength of the ~20-Hz rebound to stimulation of both impaired and healthy hand was decreased with respect to the controls in the affected (AH) and unaffected (UH) hemispheres, and increased during recovery. Importantly, the rebound strength was lower than that of the controls in the AH and UH also to healthy-hand stimulation despite of intact afferent input. In the AH, the rebound strength to impaired-hand stimulation correlated with hand motor recovery. CONCLUSIONS Motor cortex excitability is increased bilaterally after stroke and decreases concomitantly with recovery. Motor cortex excitability changes are related to both alterations in local excitatory-inhibitory circuits and changes in afferent input. Fluent sensorimotor integration, which is closely coupled with excitability changes, seems to be a key factor for motor recovery.
Collapse
Affiliation(s)
- Eeva Parkkonen
- 1 Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland.,2 Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,3 Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Kristina Laaksonen
- 1 Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland.,2 Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,3 Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Harri Piitulainen
- 1 Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
| | - Johanna Pekkola
- 4 HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Finland
| | - Lauri Parkkonen
- 1 Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
| | - Turgut Tatlisumak
- 2 Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,3 Clinical Neurosciences, University of Helsinki, Helsinki, Finland.,5 Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,6 Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Nina Forss
- 1 Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland.,2 Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,3 Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| |
Collapse
|
15
|
Veronezi BP, Moffa AH, Carvalho AF, Galhardoni R, Simis M, Benseñor IM, Lotufo PA, Machado-Vieira R, Daskalakis ZJ, Brunoni AR. Evidence for increased motor cortical facilitation and decreased inhibition in atypical depression. Acta Psychiatr Scand 2016; 134:172-82. [PMID: 27028276 DOI: 10.1111/acps.12565] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Major depressive disorder (MDD) is a clinically heterogeneous condition. However, the role of cortical glutamate and gamma-aminobutyric acid (GABA) receptor-mediated activity, implicated in MDD pathophysiology, has not been explored in different MDD subtypes. Our aim was to assess the atypical and melancholic depression subtypes regarding potential differences in GABA and glutamate receptor-mediated activity through established transcranial magnetic stimulation (TMS) neurophysiological measures from the motor cortex. METHOD We evaluated 81 subjects free of antidepressant medication, including 21 healthy controls and 20 patients with atypical, 20 with melancholic, and 20 with undifferentiated MDD. Single and paired-pulse TMS paradigms were used to evaluate intracortical facilitation (ICF), cortical silent period (CSP), and short intracortical inhibition (SICI), which index glutamate, GABAB receptor-, and GABAA receptor-mediated activity respectively. RESULTS Patients with MDD demonstrated significantly decreased mean CSP values than healthy controls (Cohen's d = 0.22-0.3, P < 0.01 for all comparisons). Atypical depression presented a distinct cortical excitability pattern of decreased cortical inhibition and increased cortical facilitation, that is, an increased mean ICF and SICI ratios than other depression subtypes (d = 0.22-0.33, P < 0.01 for all comparisons). CONCLUSION Different MDD subtypes may demonstrate different neurophysiology in relation to GABAA and glutamatergic activity. TMS as an investigational tool might be useful to distinguish between different MDD subtypes.
Collapse
Affiliation(s)
- B P Veronezi
- Interdisciplinary Center for Applied Neuromodulation, University Hospital, University of Sao Paulo, São Paulo, Brazil
| | - A H Moffa
- Interdisciplinary Center for Applied Neuromodulation, University Hospital, University of Sao Paulo, São Paulo, Brazil
| | - A F Carvalho
- Department of Psychiatry and Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceara, Brazil
| | - R Galhardoni
- Service of Interdisciplinary Neuromodulation, Laboratory of Neurosciences (LIM-27), Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.,School of Arts, Science and Humanities, University of São Paulo, São Paulo, Brazil.,Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil.,Medicine School of University City of São Paulo (UNICID), São Paulo, Brazil
| | - M Simis
- Institute of Physical Medicine and Rehabilitation, Clinics Hospital of the University of Sao Paulo Medical School, São Paulo, Brazil
| | - I M Benseñor
- Interdisciplinary Center for Applied Neuromodulation, University Hospital, University of Sao Paulo, São Paulo, Brazil
| | - P A Lotufo
- Interdisciplinary Center for Applied Neuromodulation, University Hospital, University of Sao Paulo, São Paulo, Brazil
| | - R Machado-Vieira
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health (NIH), Bethesda, MD, USA
| | - Z J Daskalakis
- Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - A R Brunoni
- Interdisciplinary Center for Applied Neuromodulation, University Hospital, University of Sao Paulo, São Paulo, Brazil.,Service of Interdisciplinary Neuromodulation, Laboratory of Neurosciences (LIM-27), Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil
| |
Collapse
|