International Workshop in Jakarta

Transcranial magnetic stimulation

- Basic theory, Methods, and Clinical applications in Physiotherapy -

Tomofumi Yamaguchi, PT, PhD

Juntendo University
t.yamaguchi.ja@juntendo.ac.jp
 Learning objectives

- To understand the meaning and clinical

importance of TMS in physiotherapy

- To understand the basic theory, methods,

and clinical application of TMS
The contents of today’s workshop

１. Introduction
- Basic theory and methods of TMS
- Clinical and research application of TMS
- Demonstration of TMS

２. Hands-on TMS
- TMS assessment and intervention
a. single-pulse TMS
b. paired-pulse TMS
c. repetitive peripheral TMS (option)
d. repetitive TMS (option)
 What is TMS?

A non-invasive brain stimulation technique

that can be used to assess and modulate
cortical and corticospinal activity.

TMS assessment provides us with an

understanding of the patient's
neurophysiological condition and the
mechanisms of cortical brain plasticity
following physiotherapy.
 How it works？

TMS produces a magnetic field that

depolarizes superficial pyramidal
neurons within the cortex.
Generally, it reaches about 5 mm
into the brain (layer Ⅱ and Ⅲ).
 TMS coils

a. Figure-8 coil
A figure-eight coil is advantageous in the localized
a. b. c.
stimulation of the brain.

b. Double-cone coil
A double-cone coil is useful in stimulating the leg
motor cortex areas via higher induced current.

c. Round coil
A round coil induces a magnetic field that is wider
and can be slightly deeper, ideal for stimulating
large parts of the brain.
 Two Main Categories of TMS
1. Assessment
: • Single-Pulse TMS

It can deliver one stimulus at a time, which assesses

cortical and corticospinal activity.

• Paired-Pulse TMS
TMS with pairs of stimuli separated by a variable interval,
which assesses intracortical inhibition (SICI) and
facilitation (ICF), interhemispheric inhibition(IHI), and
cerebellar inhibition (CBI) in the brain.

2. Therapeutic intervention
• Repetitive TMS (rTMS)
Low frequency rTMS (≤1 Hz) reduces cortical excitability.
High frequency rTMS (>5 Hz) increases cortical excitability.

Brown et al., Degenerative Neurological and Neuromuscular Disease, 2014

rTMS modulates excitability in a frequency-dependent manner

1 Hz or less

L
o
w

H
i
g
h More than 5 Hz

Chen et al, 1997; Wu et al, 2000

 rTMS

TMS Center - Southeastern Psychiatric Associates https://www.youtube.com/watch?v=NmciYGTXOBo

 Risks/side effects

➢Common
: side effects: local pain, headache, and mild discomfort
➢Could potentially displace ferromagnetic objects (e.g titanium skull plates)
➢Can induce voltages in nearby electronic devices/wires
➢Temporary increases in auditory thresholds
➢Induction of seizures
➢Syncope

Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on
training, ethical and regulatory issues: Expert Guidelines Clinical Neurophysiology 132, 2021
 repetitive Peripheral Magnetic stimulation：rPMS

rPMS, as well as peripheral nerve electrical

stimulation, can induce muscle contraction.
However, rPMS is less painful than electrical
stimulation, since the eddy current induced by
magnetic stimulation directly stimulates deep
tissues without penetrating the skin.

Nito et al, 2020

 Assessment
➢Electrophysiological parameters acquired by TMS:
predictors of excitability of motor cortex and
cortico-spinal system

◆ Motor evoked potentials (MEPs) amplitudes

◆ Latency of response (a time needed from stimulus onset
to the first component of MEP)
◆ MEP variability
◆ Central Motor Conduction Time (CMCT)
◆ Silent Period – a period of absence of bioelectric activity
◆ Motor Threshold (the strength of a stimulus inevitable to
evoke motor response of a certain quality)
Prediction of motor recovery after stroke

Shoulder Abduction and Finger Extension（SAFE）

Stinear et al., Annals of Clinical and Translational Neurology 2017; 4(11): 811–820
 TMS can be used to measure neural plasticity

▪ MEP reflects transsynaptic output

from pyramidal cells

▪ A change in synaptic strength

(within the cortical network
activated by the stimulus) will be
reflected in the MEP amplitude

▪ Change in MEP amplitude can be

used as a measure of synaptic
plasticity
Motor evoked potential (MEP)
 What is plasticity?

The ability of the brain to change, structurally and

functionally, with experience

▪Modification of synaptic strength

Long-term potentiation / long-term depression

Underlies learning and memory across the lifespan

Aid in recovery of function following brain injury

 Therapeutic mechanism of ES

Yamaguchi et al., 2012 Khaslavskaia et al,2005

Voluntary contraction combined with electrical stimulation

increase corticospinal excitability and induce neural plasticity
 Hands-on TMS
Target site: primary motor cortex (M1)
EMG recording: first dorsal interosseous (FDI) muscle or tibialis anterior (TA) muscle

Tasks:
1. Find the hotspot of the FDI or TA muscles
The hot spot was defined as the region where the largest MEP in the target muscle
could be evoked with the minimum stimulus intensity.

2. Decide the resting motor threshold (rMT) and active MT(aMT)

The rMT was defined as the minimal stimulus intensity required to induce MEPs of 50
μV (peak-to-peak amplitude) in at least three of five consecutive trials in the relaxed
muscle.
The aMT was defined as the minimal stimulus intensity required to induce MEPs of 200 μV
in at least three of five consecutive trials while the participant performed isometric wrist
extensions with an EMG amplitude of 100 μV.
 Hands-on TMS

3. Decide TMS intensity

For the single-pulse TMS, The intensity was set at 120% of the rMT to measure MEPs
as an indicator of corticospinal excitability.
For the paired-pulse TMS, conditioning stimulus intensity was set at 80% of the active
MT (aMT) of the MEP response in FDI or TA muscles. The test stimulus intensity was
set at 120% of the rMT. Throughout the experiment, the test stimulus was adjusted to
maintain an MEP amplitude equal to the ECR MEP amplitude at baseline. The inter-
stimulus interval was set at 2.5 (SICI) and 10 ms (ICF).

4. MEP changes during the following tasks

• rest condition (single-pulse TMS, paired-pulse TMS)
 Hands-on TMS

5. MEP changes during the following tasks

• voluntary contraction with 5%MVC, 20%MVC, 50%MVC
• motor imagery with 5%MVC, 20%MVC, 50%MVC

6. MEP changes after the following task

• repetition of voluntary contraction
• repetitive peripheral magnetic stimulation (option)
• repetitive transcranial magnetic stimulation (option)