Repetitive Transcranial Magnetic Stimulation for Rehabilitation Workshop
Restoring neural circuitry through non-invasive brain stimulation. The brain is a complex organ, containing numerous neural networks which regulate sensory perception, attention, motivation and action (movement). These networks must interact synergistically to generate even the most basic behavioral tasks. When one of these neural networks is damaged by a stroke or traumatic brain injury, execution of these tasks is fundamentally impaired. Fortunately, emerging brain stimulation research demonstrates that it may be possible to restore activity in these neural circuits and improve sensorimotor function in our patients.
Repetitive transcranial magnetic stimulation (rTMS) is an FDA-approved treatment for depression and is currently being investigated as a tool to aid motor rehabilitation in patients with stroke and spinal cord injury as well as improve motor symptoms in neurologic disorders such as Parkinson’s disease and Tourette Syndrome. Through rTMS it is possible to increase or decrease cortical (and subcortical) excitability by applying various frequencies of stimulation to different cortical sites. In the domain of stroke rehabilitation, common strategies of rTMS trial design include 1) increasing cortical excitability in the injured motor/premotor cortex, and 2) decreasing cortical excitability in the hemisphere not directly affected by the stroke. While this is typically done with fixed frequency protocols, there is an increasing interest in using patterned protocols such as theta burst stimulation. Furthermore, there is increasing data that suggesting there are clinical, genetic, and demographic variables that contribute to the efficacy of rTMS as a successful treatment for a given individual. Although there is neither a widely accepted nor FDA-approved protocol for motor rehabilitation, the opportunities for innovation and discovery in this field is plentiful. This is due in part to a growing emphasis on robust clinical trial design and novel brain stimulation protocols.
The goal of this workshop is to provide participants with hands-on opportunities to learn and practice the fundamentals of rTMS, neuronavigation, and robust experimental design. . In this workshop students will learn to acquire rTMS data, design well-controlled studies, and use neuronavigation to select and maintain a cortical target. The course will be taught by NIH –funded researchers and clinicians. Students will end the course with an original data set which they collected & analyzed, and an abstract which summarizes their findings.
- Acquire the essential knowledge about rTMS protocols
- Understand the basic neurobiology that is occurring in the acute and chronic phases of stroke recovery.The timecourse of neuroplasticity is critical to choosing a therapeutic strategy.
- Understand the relationship between frequencies of stimulation and their effect on cortical excitability,with specific emphasis applied to variability observed in the commonly used fixed frequency and
patterned frequency protocols.
- Understand human subjects factors that will affect the dosing, tolerability, and efficacy of rTMStreatment delivery (e.g. scalp-cortex distance, baseline motor impairment, BDNF genotype)
Activity / methods
- Didactic and interactive lectures on clinical neurobiology, and clinical TMS delivery.
- Interactive discussion on proper study design including robust sham controls.
- Hand’s on training on neuronavigation
- Hands-on review of basic motor threshold acquisition (Note: previous experience with TMS is requiredfor this course)
- Hands-on introduction to repetitive TMS at various fixed-frequency and patterned-frequencyparadigms
- Design a sham-controlled study testing the efficacy of an rTMS paradigm utilizing neural circuitry and neural navigation as a guide.
- Acquire a set of motor evoked potential data
- Become comfortable utilizing neuronavigation software as a tool to both select a target and maintainpositioning.
Activity / methods
- Interactive feedback session on potential study design
- Practice neuronavigation
- Practice acquiring motor evoked potential data
- Acquire a set of motor evoked potential data which can be analyzed on Day 3.
- Learn to analyze MEP data from the arm or leg (from data collected on Day 2 and sample data sets)(performed by each student at individual workstations)
- Present the results to the group and compose an abstract.
- Get personalized feedback on questions you may have about setting up an RTMS lab at your institution
- Get personalized feedback on your grant ideas and how these data may help you move forward withyour own study designs.
Activity / methods
- Analyze MEP data
- Refine an abstract which you started on Day 1 based on the data collected in Day 2, and resultsobserved in Day 3.
- Present your results to the group.
- One-one one interactions with the workshop staff regarding your grant ideas or information aboutsetting up your own laboratory.