The Possibilities of Noninvasive Brain Stimulation (Podcast)

The FDA has approved transcranial magnetic stimulation (TMS), a form of noninvasive brain stimulation, for treating depression, diagnosing epilepsy and conducting presurgical mapping for epilepsy. Ela Plow, PhD, PT, envisions broader use of TMS to treat patients with upper motor neuron conditions and upper or lower limb motor impairment from stroke or multiple sclerosis.

Combining advanced imaging with TMS could help bridge the gap between understanding what part of the brain remains functional and ascertaining how it functions, says Dr. Plow, a researcher in Cleveland Clinic’s Department of Biomedical Engineering and Neurological Institute.

“Once we have that insight, we can close the loop on understanding the true potential that a patient may have,” says Dr. Plow.

In the most recent episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Plow discusses the current landscape of noninvasive brain stimulation and what lies on the horizon. She delves into:

• Using patterned pulses of stimulation to target specific brain regions
• The latest model of movement recovery in stroke
• The effect of stroke types on neurorestorative treatments
• The TMS treatment path for patients with stroke
• The potential of TMS to treat patients with epilepsy, spinal cord injury, mood disorders and other conditions

Click the podcast player above to listen to the episode now, or read on for a short edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: Can you walk us through your typical stimulation methods and targets?

Ela Plow, PhD: Sure, so let’s take stroke for example, because we have a large stroke population here at Cleveland Clinic. We are specialized in the area of severe strokes. So these are patients who can’t be participating in regular clinical trials of rehab. They’re generally excluded. So a patient is quite impaired, has severe upper limb hemiplegia. And our goal, in this case, through the NIH clinical trial that we’re conducting, is to tap into or target their intact or good hemisphere as a means of potentially promoting any recovery that may be possible to achieve.

So a patient comes in, we have a workup with the neurologist and a therapist as well as an imaging-related workup that defines where the stroke lies, what areas are remaining, what areas in the intact hemisphere are likely to act as substrates of recovery, based on functional imaging and resting state functional connectivity imaging. With all of this imaging and clinical and therapy workup, we are able to start our treatments, which involve the pattern of therapeutic modes of transcranial magnetic stimulation, which we call repetitive TMS or rTMS, with many different types of frequencies.

Basically the patient sits down, and we have their MRI and the functional imaging available from their brain. And with that, we also have the surface EMG placed on different muscles on their paretic side and nonparetic side. And we’re able to evaluate how much conduction we are still able to see. This is done with single pulses of TMS. This helps us diagnose the potential of the remainder of the pathways that these individuals have.

Once we know that we have a readout on the baseline, then we’re able to begin treatments. So if the patient is assigned to receive treatment to the good hemisphere, then we target certain higher motor regions of the good hemisphere based on the imaging workup and also the neurophysiological workup received with TMS. So with a combination of this, we will run those patterns, stimulation paradigms, and immediately the patient is treated with upper extremity rehab very similar to everything that we do in the clinic here as standard of care. After completion of that rehab, we do certain questionnaires to make sure that everything was safe, there’s no neck pain, scalp pain, et cetera, which are based on reports of minor, slightly uncomfortable responses to any type of brain stimulation.