J Neurophysiol 103: 1735–1740, 2010.
First published January 27, 2010; doi:10.1152/jn.00924.2009.
Shaping the Optimal Repetition Interval for Cathodal Transcranial Direct
Current Stimulation (tDCS)
Katia Monte-Silva,* Min-Fang Kuo,* David Liebetanz, Walter Paulus, and Michael A. Nitsche
Department of Clinical Neurophysiology, Georg-August-University, Göttingen, Germany
Submitted 15 October 2009; accepted in final form 22 January 2010
Monte-Silva K, Kuo M-F, Liebetanz D, Paulus W, Nitsche MA.
Shaping the optimal repetition interval for cathodal transcranial direct
current stimulation (tDCS). J Neurophysiol 103: 1735–1740, 2010.
First published January 27, 2010; doi:10.1152/jn.00924.2009. Trans-
cranial DC stimulation (tDCS) is a plasticity-inducing noninvasive
brain stimulation tool with various potential therapeutic applications
in neurological and psychiatric diseases. Currently, the duration of the
aftereffects of stimulation is restricted. For future clinical applica-
tions, stimulation protocols are required that produce aftereffects
lasting for days or weeks. Options to prolong the effects of tDCS are
further prolongation or repetition of tDCS. Nothing is known thus far
about optimal protocols in this behalf, although repetitive stimulation
is already performed in clinical applications. Thus we explored the
effects of different break durations on cathodal tDCS-induced cortical
excitability alterations. In 12 subjects, two identical periods of
cathodal tDCS (9-min duration; 1 mA) with an interstimulation
interval of 0 (no break), 3, or 20 min or 3 or 24 h were performed. The
results indicate that doubling stimulation duration without a break
prolongs the aftereffects from 60 to 90 min after tDCS. When the
second stimulation was performed during the aftereffects of the first,
a prolongation and enhancement of tDCS-induced effects for ⱕ120
min after stimulation was observed. In contrast, when the second
stimulation followed the first one after 3 or 24 h, the aftereffects were
initially attenuated, or abolished, but afterwards re-established for up
to 120 min after tDCS in the 24-h condition. These results suggest
that, for prolonging the aftereffects of cathodal tDCS, stimulation
interval might be important.
INTRODUCTION
Transcranial DC stimulation (tDCS), a noninvasive, neuro-
plasticity-generating brain stimulation tool, is increasingly
used for therapeutic purposes in neurological and psychiatric
diseases accompanied by pathological alterations of cortical
excitability and activity, such as epilepsy (Fregni et al. 2006c;
Liebetanz et al. 2006), migraine (Antal et al. 2008; Chadaide et
al. 2007), stroke (Boggio et al. 2007; Hummel et al. 2005;
Schlaug et al. 2008), and depression (Boggio et al. 2008;
Fregni et al. 2006a). By application of a weak DC, tDCS elicits
cortical excitability changes in the human brain in a painless
and reversible way (Nitsche and Paulus 2000). The induced
excitability alterations depend on the duration, current density,
and direction of the current flow. Anodal stimulation enhances
excitability, whereas cathodal stimulation reduces it (Nitsche
and Paulus 2000, 2001; Nitsche et al. 2003b). In the currently
available protocols, tDCS has been shown to modify cortical
excitability for up to ⬃1 h after stimulation (Nitsche and
* These authors contributed equally to this work.
Address for reprint requests and other correspondence: M. A. Nitsche, Dept.
of Clinical Neurophysiology, Georg-August-Univ., Robert-Koch-St. 40, 37075
Göttingen, Germany (E-mail: mnitsch1@gwdg.de).
www.jn.org 0022-3077/10 $8.00 Copyright © 2010 The American Physiological Society
Paulus 2001; Nitsche et al. 2003b). For clinical purposes,
however, longer-lasting effects are needed. In principle, these
can be achieved by prolonging stimulation duration or enhanc-
ing stimulation strength, and both have been done in clinical
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applications (Ferrucci et al. 2009; Fregni et al. 2006b; Ohn et
al. 2008). Although these protocols are well within safety
limits (Liebetanz et al. 2009), it is a general goal to keep
current exposition as low as possible. Moreover high-intensity
stimulation might be painful (Furubayashi et al. 2008) and
affect different neuronal populations, compared with weaker
stimulation, because of increased stimulation depth, which
might not be intended in each case. Another option to prolong
the aftereffects of tDCS might be the repetition of tDCS
sessions. Functionally, repetitive tDCS has been shown to
induce cumulative effects when applied once daily in humans
(Boggio et al. 2007, 2008). It is, however, unclear whether this
repetition rate (stimulation once daily) is optimal suited to
stabilize tDCS-induced plasticity. In animal experiments, rep-
etition of DC stimulation during the aftereffects of a first
stimulation session has been shown to enhance its efficacy
(Bindman et al. 1964; Gartside 1968). However, repeated
plasticity induction might also result in homeostatically driven
antagonistic effects (Siebner et al. 2004). Here we aimed to
explore repetitive tDCS protocols, which could lead to longer
duration and stabilization of the stimulation aftereffects. We
compared single sessions of cathodal tDCS with the effects of
repetitive stimulation during or after the aftereffects of the first
stimulation.
METHODS
Subjects
Twelve different healthy volunteers took part in each stimulation
protocol: tDCS applied constantly for 9 min (9-0-0 protocol), five
men, seven women, 24.31 ⫾ 6.1 (SD) yr of age; for 18 min (9-0-9
protocol), four men, eight women, 26.83 ⫾ 6.2 yr of age; tDCS
applied with interstimulation intervals of 3 min (9-3-9 protocol), six
men, six women, 25.73 ⫾ 5.52 yr of age; with interstimulation
intervals of 20 min (9-20-9 protocol), five men, seven women;
25.96 ⫾ 4.18 yr of age; interstimulation intervals of 3 h (9-3h-9
protocol), six men, six women; 26.23 ⫾ 7.18 yr of age; and inter-
stimulation intervals of 24 h (9-24h-9 protocol), six men, six women;
27.58 ⫾ 6.13 yr of age. Age (t-test, P ⬎ 0.05) and sex (␹2, P ⬎ 0.05)
did not differ significantly between the groups of participants. The
subjects were between 18 and 45 yr old and had no history of chronic
or acute neurological, psychiatric, or medical disease, no family
history of epilepsy, no pregnancy, no cardiac pacemaker, and no
previous surgery involving implants to the head (cochlear implants,
aneurysm clips, brain electrodes). Subjects were recruited from the
campus of the Georg-August-University. Before the sessions, written
informed consent was obtained. The experiments were approved by
1735
1736 MONTE-SILVA, KUO, LIEBETANZ, PAULUS, AND NITSCHE
the ethics committee of the University of Göttingen, and we con-
formed to the Declaration of Helsinki. Each experiment was con-
ducted in a repeated-measures design.
Direct current stimulation of the motor cortex
Continuous direct currents were transferred by saline-soaked sur-
face sponge electrodes (35 cm2) and delivered by a specially devel-
oped, battery-driven constant current stimulator (Schneider Elec-
tronic, Gleichen, Germany) with a maximum output of 2 mA. The
motor cortical electrode was positioned over the motor cortex repre-
sentational area of the right abductor digiti minimi muscle (ADM), as
identified by transcranial magnetic stimulation (TMS), and the other
electrode above the right orbit. This electrode arrangement is known
to result in significant excitability changes in the human motor cortex
(Nitsche and Paulus 2000). tDCS was applied once or twice (see
METHODS) with a current intensity of 1 mA for 9 min (cathodal tDCS),
which induces cortical excitability diminutions lasting for ⬃1 h after
the end of stimulation (Nitsche et al. 2003b).
Monitoring of motor cortical excitability
TMS-elicited motor-evoked potentials (MEPs) were recorded to
monitor excitability changes of the representational motor cortical
area of the right ADM. Single-pulse TMS was conducted by a
Magstim 200 magnetic stimulator (Magstim, Whiteland, Dyfed, UK)
with a figure-of-eight magnetic coil (diameter of 1 winding ⫽ 70 mm,
peak magnetic field ⫽ 2.2 T). The coil was held tangentially to the
skull, with the handle pointing backward and laterally at an angle of
45° from midline. The optimal position was defined as the site where
stimulation resulted consistently in the largest MEPs. Surface EMG
was recorded from the right ADM with Ag-AgCl electrodes in a
belly-tendon montage. The signals were amplified and filtered with a
time constant of 80 ms and a low-pass filter of 2.0 kHz and then
digitized at an A/D rate of 5 kHz and further relayed into a laboratory
computer using the Signal software and CED 1401 hardware (Cam-
bridge Electronic Design, Cambridge, UK). The intensity was ad-
justed to elicit, on average, baseline MEPs of 1 mV peak-to-peak
amplitude and was kept constant for the poststimulation assessment.
Experimental procedures
The experiments took place in an air-conditioned laboratory with a
constant temperature of 20°C to guarantee constant skin temperature
throughout the experimental sessions. The volunteers were seated in a
comfortable chair with head and arm rests. The left motor-cortical
representational field of the right ADM was identified using TMS (the
coil position that produced to the largest MEPs in the resting ADM–
optimal site). Identification of the hot spot took ⬃20 –30 min in each
subject. For all stimulation protocols, the intensity of the magnetic
cortical stimulus was adjusted to elicit MEPs with a peak-to-peak
amplitude of on average 1 mV. Determination of baseline TMS
intensity took 5–10 min for each subject. Twenty-five MEPs were
recorded after stable MEP amplitudes were obtained, at a frequency of
0.25 Hz for baseline determination. The motor cortical tDCS electrode
was fixed on the ADM hot-spot, and the other was fixed at the
contralateral forehead, just above the orbit. Afterward, motor cortical
tDCS was performed as follows.
Experiment A
This experiment was designed to explore the effect of single
cathodal tDCS applied constantly for 9 (9-0-0 protocol) or 18 min
(9-0-9 protocol) on motor cortex excitability.
J Neurophysiol • VOL
Experiment B
We studied the changes of cortical excitability after a second
cathodal stimulation, applied during the aftereffects of the first, i.e.,
with short interstimulation intervals of 3 (9-3-9 protocol) or 20 min
(9-20-9 protocol).
Experiment C
We tested the effect of the second cathodal stimulation when it
followed the first after long interstimulation intervals: 3 (9-3h-9
protocol) or 24 h (9-24h-9 protocol).
Immediately after the last tDCS session, 25 MEPs were recorded
every 5 min at 0.25 Hz for 0.5 h and then every 30 min up to 2 h after
the end of each stimulation. The TMS recordings were also performed
at four additional time points: same day evening (se), next morning
(nm), next afternoon (na), and next evening (ne). Because we did not
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expected longer-lasting aftereffects induced by the 9-0-0 and 9-0-9
protocols, here the aftereffects of tDCS were evaluated until 120 min
and until the same evening after the stimulation, respectively. To
guarantee optimal coil positioning during the course of the experi-
ment, it was regularly checked whether the actual coil position elicited
the largest MEPs during the aftereffect measures. The EMG electrode
and coil positions were marked with a waterproof pen to guarantee
identical positions during the whole course of the experiments. Ex-
perimental procedures are summarized in Fig. 1.
Data analysis and statistics
MEP amplitude means were calculated for each time bin covering
baseline and poststimulation values. The poststimulation MEPs were
normalized intraindividually and are given as ratios of the baseline.
An ANOVA model for repeated measures for the time bins ⱕ120 min
after tDCS was calculated with the dependent variable MEP ampli-
tude, with time course as the within-subject factor and tDCS inter-
stimulation interval (9-0-0; 9-0-9; 9-3-9;9-20-9; 9-3h-9; and 9-24h-9)
as the between-subject factor. Additionally paired-samples and inde-
pendent-samples Student’s t-test were used 1) for baseline compari-
sons between the tDCS different protocols, 2) to test whether the MEP
amplitudes after tDCS differed significantly from the pre-DC ampli-
tudes, and, in case of the 3- and 24-h intervals, 3) if later occurring
MEP reductions differed from initial post-DC MEPs. Furthermore,
t-tests were applied to explore if MEPs differed for the single time bins
between the respective tDCS protocols. A P value of ⬍.05 was consid-
ered significant for all statistical analyses. All results are given as mean
and SE. An additional three-factorial ANOVA with the dependent vari-
able MEP amplitude, time course as the within-subject factor, and tDCS
interstimulation interval (9-0-0; 9-0-9; 9-3-9;9-20-9; 9-3h-9; and
9-24h-9) and sex as between-subject factors was calculated to rule out an
effect of sex on the results (Supplemental Table S1).1
The Mauchly test of sphericity was checked, and the Greenhouse-
Geisser correction was performed, when appropriate.
RESULTS
The results of the ANOVA showed significant main
effects of time course (F ⫽ 11.14; df ⫽ 6/4,260; P ⬍ 0.001)
and tDCS interstimulation interval (F ⫽ 4.13; df ⫽ 5/426;
P ⬍ 0.05) and a significant interaction of time course ⫻
tDCS interstimulation interval (F ⫽ 1.32; df ⫽ 10/4,260;
P ⬍ 0.001). After continuous cathodal tDCS, cortical ex-
citability was reduced for 60 min by 9 min (9-0-0 protocol)
and for 90 min by 18 min (9-0-9 protocol) tDCS, respec-
tively (Fig. 2A). When the second cathodal stimulation was
performed during the aftereffects of the first (9-3-9 and
9-20-9 protocols), a prolongation of tDCS-induced excit-
103 • APRIL 2010 • www.jn.org
 REPETITIVE CATHODAL tDCS 1737

Baseline MEPs Current Stimulation Post tDCS MEPs

Stimulation
Parameters

Single Pulse TMS Repeated Single Pulse TMS

0.25 Hz Cathodal tDCS

1mA 0.25 Hz
1mV
1mV

9-0-0 protocol
9 min.

Experiment A tDCS

No intervals 9-0-9 protocol

9 min. 9 min.

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tDCS tDCS

9-3-9 protocol
BASELINE
PROTOCOL

9 min. 9 min.
3m
tDCS tDCS
Experiment B Pause
Short intervals 9-20-9 protocol

9 min. 20 min. 9 min.

tDCS Pause tDCS

9-3h-9 protocol

9 min. 3 hours 9 min.

Experiment C tDCS Pause tDCS
Long intervals 9-24h-9 protocol

9 min. 24 hours 9 min.

tDCS Pause tDCS

0 5 10 15 20 25 30 60 90 120 se nm na ne

Time after tDCS

FIG.
1. Experimental course. First, transcranial magnetic stimulation (TMS) was applied over the left motor cortical representational area of the right
ADM with an intensity to elicit motor evoked potentials (MEPs) with a peak-to-peak amplitude of on average 1 mV (baseline determination). Afterward,
motor cortical cathodal transcranial direct current stimulation (tDCS; 1 mA; 9 min) was performed as follows: 1) experiment A (no intervals), a) single
tDCS for 9 min (9-0-0 protocol) and b) single tDCS for 18 min (9-0-9 protocol); 2) experiment B (short intervals), a) repeated tDCS with inter-tDCS pause
of 3 min (9-3-9 protocol) and b) repeated tDCS with inter-tDCS pause of 20 min (9-20-9 protocol); and 3) experiment C (long intervals), a) repeated tDCS
with inter-tDCS pause of 3 h (9-3h-9 protocol) and b) repeated tDCS with inter-tDCS pause of 24 h (9 –24 h-9 protocol). For experiments 2 and 3, the
aftereffects of tDCS were evaluated by TMS up to next evening after intervention. For experiment 1, TMS recordings were performed until 120 min and
until the same evening after the stimulation for 9-0-0 and 9-0-9 paradigms, respectively. ne, next evening; nm, next morning; na, next afternoon; se, same
evening.

ability diminution for ⱕ120 min after stimulation was
observed. Compared with the 9-0-0, the 9-20-9 and 9-3-9
protocols prolonged the inhibitory effects generated by
cathodal tDCS from 60 to 120 min after stimulation. Fur-
thermore, the aftereffects were significantly enlarged in the
9-20-9 condition for ⬃15–20% compared with the 9-0-0
condition (Fig. 2B). When the second cathodal stimulation
was applied 3 (9-3h-9) or 24 h (9-24h-9) after the first
stimulation, the cathodal tDCS-induced inhibitory afteref-
fects were attenuated or abolished during the first 30 min
after stimulation. The 9-3h-9 protocol abolished the inhib-
itory effect of cathodal tDCS until 60 min after stimulation;
a relevant inhibitory effect appeared only 60 min after the
second tDCS session. For the 9-24h-9 protocol, the excit-
ability-diminishing effects of cathodal tDCS were more
relevantly delayed and prolonged until 120 min after the end
of stimulation (Fig. 2C). Comparison of the 9-0-0 with the
other stimulation conditions shows that 18-min continuous
stimulation (9-0-9 condition) prolongs the aftereffects for
ⱕ120 min after stimulation. The same result emerges for the
J Neurophysiol • VOL
9-3-9 and the 9-20-9 conditions. For the 9-20-9 condition,
the tDCS-induced inhibition is additionally significantly
larger than the inhibition accomplished by 9-0-0 stimula-
tion. With regard to the long breaks, inhibition was signif-
icantly reduced, if the second stimulation followed the first
after a 3-h break for 25 min after tDCS, and a trend for such
an effect was seen for the 24-h break condition compared
with the 9-0-0 stimulation protocol (for results of the single
t-test, see Supplemental Table S2).
Comparison of the 9-0-9 condition with the 9-20-9 condition
to explore which protocol was optimally suited to enhance the
aftereffects of cathodal tDCS shows that a 20-min break
between stimulation conditions results in a significantly in-
creased magnitude of the excitability diminutions between 20
and 30 min after tDCS, whereas the duration of the aftereffects
only differed trendwise between these conditions, with some
advantage for the 20-min break session (Supplemental Table
S2). Sex did not affect the inhibitory impact of cathodal tDCS
on motor cortex excitability (for the results of the ANOVA, see
Supplemental Table S1).
103 • APRIL 2010 • www.jn.org
1738 MONTE-SILVA, KUO, LIEBETANZ, PAULUS, AND NITSCHE

A
9-0-0
1.2 9-0-9
MEP Amplitude Baseline

0.8 #

0.6
FIG. 2. Effects of different temporal intervals of repeated
cathodal tDCS on modulations of cortical excitability. Shown is
0.4
the time course of baseline-standardized MEP amplitudes elic-
B 1.4 9-3m-9 ited by single-pulse TMS after repeated tDCS applied with
9-20m-9 different interstimulation intervals. A: when cathodal tDCS was
applied constantly for 9 (9-0-0 condition) or 18 min (9-0-9
1.2
MEP Amplitude Baseline

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protocols), it resulted in a cortical excitability diminution last-
ing longer after 18 min tDCS. B: when the 2nd stimulation was
1 performed during the aftereffects of the 1st, i.e., with short
interstimulation intervals (9-3-9 and 9-20-9 protocols), a pro-
longation of tDCS-induced effects for ⱕ120 min after stimu-
0.8 lation was observed. For the 20-min interval, the magnitude of
inhibition was furthermore enhanced. C: when the 2nd stimu-
lation followed the 1st after 3 or 24 h (9-3h-9 and 9-24h-9
0.6 #
# #
# #
# # protocols), the cathodal tDCS-induced inhibitory aftereffects
were attenuated. Filled symbols indicate significant deviations
0.4
of the post-tDCS MEP amplitudes from baseline values; #
marks significant deviations of each tDCS protocol from the
9-3h-9 9-0-0 protocol (t-test, independent samples, P ⬍ 0.05). Error
C 1.4 9-24h-9 bars indicate SE. ne, next evening; nm, next morning; na, next
afternoon; se, same evening. *Significant difference between
MEP Amplitude Baseline

1.2 # # # #
# #
the baseline-standardized MEPs marked by brackets.

#
0.8

0.6
* #
*
0.4
0 5 10 15 20 25 30 60 90 120 se nm na ne
Time course (min after tDCS)

DISCUSSION continuous stimulation duration without a break for 18 min

This is the first study showing that 1) prolongation of
cathodal tDCS duration is able to prolong the aftereffects
relevantly beyond 1-h duration and that 2) for fractionated
application of tDCS, the interstimulation break is of critical
importance. Prolonging stimulation duration from 9 to 18 min
relevantly prolonged the afterefeects of cathodal tDCS from 60
to 90 min. When the second tDCS session was performed
during the aftereffects of the first, inhibitory plasticity was
enhanced and prolonged for ⱕ120 min after tDCS compared
with 9-min tDCS. Conversely, if the second stimulation was
performed 3 or 24 h after the first one, tDCS had a more mixed
effect on cortical excitability, with a primary reduction, but
later reoccurrance of tDCS-induced cortical inhibition.
Repetitive tDCS: the importance of timing
Concordant with previous data, a single session of 9-min
cathodal tDCS produced inhibitory aftereffects on cortical
excitability lasting for an hour after the end of stimulation
(Nitsche and Paulus 2001; Nitsche et al. 2003b). Prolonging
J Neurophysiol • VOL
increased the duration of the aftereffects; however, it was less
exaggerated than the duration increase between 5-, 7-, and
9-min stimulation shown in a previous study (Nitsche et al.
2003b). This result confirms principally those of previous
studies that suggested that the duration of tDCS-induced plas-
ticity is related to stimulation duration (Bindman et al. 1964;
Nitsche and Paulus 2000); however, as shown here, a satura-
tion effect might apply. The main finding of our study is that
repeating cathodal tDCS during the aftereffects of the first
session prolongs the duration of the aftereffects for 1 h and
increases their amplitude. Interestingly, the magnitude of
cathodal tDCS-induced inhibition was only enhanced when the
second followed the first stimulation session after an interses-
sion interval of 20 min but not 3 min. In contrast, applying the
second session after the aftereffects of the prior tDCS session
on MEP amplitude vanished, i.e., 3 or 24 h after the first
session, reduces or abolishes the initial effects of cathodal
tDCS for ⱕ60 min after stimulation. However, a delayed
excitability diminution was apparent 60 (3- and 24-h break
conditions) and ⱕ120 min (24-h condition only) after the
103 • APRIL 2010 • www.jn.org
 REPETITIVE CATHODAL tDCS
second stimulation session. Taken together, our results are
indicative for a stimulation timing– dependent plasticity regu-
lation in the human motor cortex. Specifically, a second stim-
ulation session performed during the aftereffects of the first is
suited to prolong and enhance the magnitude of tDCS-induced
excitability diminution. This result is consistent with early
animal experimentation in DC stimulation, which furthermore
suggests that these effects are protein synthesis dependent
(Bindman et al. 1964; Gartside 1968). A similar effect is also
described for spinal plasticity (Jung et al. 2009).
Proposed mechanisms of action of prolongation of the
aftereffects of tDCS by repetitive cathodal tDCS
Interestingly, repetition of tDCS had a different impact on
inhibitory plasticity depending on the break between sessions.
Specifically a second stimulation performed during the after-
effects of the fist one resulted in enhanced amplitude and
duration of the aftereffects of cathodal tDCS, which was
slightly larger than the efficacy enhancement of stimulation
accomplished by pure prolongation of stimulation without a
break. Such cumulative effects of repetitive plasticity-inducing
stimulation have been also shown for long-term depression
(LTD) protocols in slice preparations (Kamikubo et al. 2006;
Shinoda et al. 2005). Here, repetitive LTD induction resulted in
long-lasting excitability diminutions, which were dependent on
protein phosphatase and metabotropic gluatamate receptors
and resulted in a reduction in the number of functional AMPA
receptors in the postsynaptic density. Although in the reported
studies the aftereffects explored were much longer lasting than
those in this one, the principle mechanism of action might be
similar. Beyond slice experiments, systematic physiological
studies exploring cumulative effects of repeated plasticity in-
duction are rare. However, simulation and cognitive studies
exploring the optimum repetition interval for learning tasks and
stabilization of plasticity propose that there might be a re-
stricted time window to improve functions (Hotermans et al.
2006; Langemann et al. 2008; Matsumoto and Mizunami 2002;
Pavlik and Anderson 2008). Specifically, an early “viscosity”
phase was suggested, which encompasses alterations of N-
methyl-D-aspartate (NMDA) and CaMKII activity, and only
turns into stable plasticity if repeated excitation causes the
subsequently temporarily altered concentrations of AMPA sub-
units in the postsynaptic membrane to be stabilized (Lange-
mann et al. 2008). Because it is known that tDCS effects
depend on activation of NMDA receptors (Liebetanz et al.
2002; Nitsche et al. 2003a), such a mechanism, which, how-
ever, has to be substantiated further experimentally, could
explain the prolonging effect of a second tDCS session during
the aftereffect of the first, and also the absence of such a
cumulative action of the second stimulation, if it is applied
after the aftereffects of the first stimulation have vanished. The
reduced effect of repeated tDCS on excitability, which is
accomplished when the second stimulation is applied hours
after the first one, is not completely explained by this mecha-
nism. Thus far, tDCS aftereffects have mainly be quantified by
single-pulse TMS; however, this effect shows that the impact
of tDCS lasts longer than the overt effects on cortico-spinal
excitability and is a first hint toward separate presumably
intracortical plasticity mechanisms. It might be argued that
some stabilization of plasticity takes place during that pro-
J Neurophysiol • VOL
1739
longed period, which makes it more difficult for further inter-
ventions to induce plastic alterations. In that way, this effect is
similar to homeostatic mechanisms of neuroplasticity regula-
tion, which are postulated to limit neuroplastic alterations to
avoid neuronal network destabilization and have been shown to
work within similar time frames in animals (Abbott and Nelson
2000; Abraham and Tate 1997; Davis 2006; Turrigiano and
Nelson 2004). For humans, homeostatic mechanisms have also
been shown but only within a much shorter time course (Bliem
et al. 2008; Iyer et al. 2003; Lang et al. 2004; Müller et al.
2007; Nitsche et al. 2007; Siebner et al. 2004). The reason for
missing homeostatic effects with regard to short-term breaks
between stimulation, and their restriction to long-term intervals in
this experiment, might depend on the specific plasticity induction
protocols used in the different studies. Whereas we applied tDCS
in the present study, repetitive transcranial magnetic stimulation,
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or paired associative stimulation, in some studies in combination
with tDCS, were administered in the preceding-mentioned stud-
ies. These protocols differ in focality of effects, timing depen-
dency, supra- versus subthreshold stimulation, and duration and
magnitude of the aftereffects. Differences in these factors might
be responsible for the seemingly opposing effects and should be
explored systematically in future experiments. Interestingly, even
not in all of the above-mentioned studies, in which other plasticity
induction procedures than tDCS were applied, homeostatic plas-
ticity was induced.
General remarks
The results of this study deliver the first neurophysiological
evidence that 1) fractionation of cathodal tDCS is suited to
prolong its inhibitory neuroplastic effects and 2) specific timing of
repetition intervals is important for optimizing cumulative effects.
tDCS is increasingly used for therapeutic purposes, with some
promising initial results in pain treatment, motor rehabilitation
after stroke, and epilepsy therapy, among others (Fregni et al.
2005, 2006a,b,c; Hummel et al. 2005). Here neuroplastic excit-
ability alterations are needed that last for days or weeks. In
exploring fractionated tDCS protocols, which are optimally suited
to induce long-lasting neuroplastic cortical excitability alterations,
the results of this study might help to develop tDCS protocols
optimized for clinical application.
Interestingly, MEP variations tended to increase, both intra-
and intraindividually, with larger time lags between the exper-
iments (Supplemental Fig. S1). Although this might at least in
part be explained by methodological aspects, e.g., slight dif-
ferences of electrode or coil positions between MEP measures,
it may also be caused by physiological alterations. Long
intervals between plasticity induction procedures might be
more prone to spontaneous changes of cortical activity and
excitability, possibly related to diurnal or other variations,
which could affect the efficacy of plasticity induction proce-
dures. Moreover, these changes, which might differ between
individuals, could have an impact on the interaction of the
consecutive stimulation protocols.
Beyond tDCS, fractionation might also be important for other
therapeutically applied neuroplasticity induction procedures, such
as repetitive transcranial magnetic stimulation (rTMS). Currently
in most clinical studies, rTMS is applied once daily. Our results
indicate that the initial excitability decrease might be suboptimal
within the first 30 min when the repeated stimulation is applied
103 • APRIL 2010 • www.jn.org
1740 MONTE-SILVA, KUO, LIEBETANZ, PAULUS, AND NITSCHE
after 24 h. This should be taken into account in the development
of treatment protocols with a technique that is expected to have
effective therapeutic purposes. It also shows that MEPs should be
studied with a delay in 24-h repetitive stimulation protocols when
used as a surrogate marker. Otherwise, the main effect may be
missed. Systematic studies are needed to explore whether these
protocols are really optimally suited for achieving the intended
functional effects.
GRANTS
K. Monte-Silva is supported by Coordenação de Aperfeicoamento de
Pessoal de Nı́vel Superior, Brazil. This project was further supported by the
German Ministry for Education and Research, Bernstein Center for Compu-
tational Neuroscience, Goettingen, and the Rose Foundation.
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