repetitive transcranial magnetic stimulation or transcranial direct current stimulation?
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Repetitive transcranial magnets
tion (TMS) uses a large, rapidly changing magnetic field
electric nerve stimulator. These short pulses initiate action
delivering weak direct current (1-2mA) through a sponge
enters the skull where it is thought to polarize cortical
of neurons will tend to change their average level ofdischarge. Although brain polarization has been reintro-duced only recently, it has a very long history and wasused in the 19th and 20th centuries for the treatment of
Correspondence: Prof. Alberto Priori, Dipartimento di Scienze Neuro-
logiche, Universita` di Milano, Ospedale Maggiore Policlinico di Milano,
Via Francesco Sforza 35, 20122 Milano, Italy.
E-mail address: email@example.com
Submitted January 7, 2009; revised February 17, 2009. Accepted for
Brain Stimulation (2009) 2, 2415potentials in axons of the cortex and subcortical whitematter that then release neurotransmitters at their terminal
neurons. Theoretically, depending on the orientation ofthe cells with respect to the current, the membranepotentials may be hyperpolarized or depolarized bya few mV. It is important to note that tDCS does notinduce action potentials in axons. However, polarization
JCR was funded by the Medical Research Council, UK.
MH is supported by the Intramural Program of NINDS, NIH.to induce electrical stimulating currents in the brain thatare similar to those that are produced by a conventional
electrode placed on the scalp for periods of 4-5 seconds tomore than 20 minutes. A portion of the applied currentKeywords rTMS; tDCS; brain stimulation; neuromodulation
In recent years two techniques have become availableto stimulate the human brain painlessly and noninvasivelythrough the intact scalp. Transcranial magnetic stimula-
synapses. Stimulators can deliver either single pulses orrepeated pulses (rTMS) at frequencies of up to 50 Hz.Transcranial direct current stimulation (tDCS) involvesIn recent years two techniques have become available to stimulate the human brain noninvasivelythrough the scalp: repetitive transcranial magnetic stimulation (rTMS) and transcranial direct currentstimulation (tDCS). Prolonged application of either method (eg, several hundred TMS pulses [rTMS]or several minutes of tDCS) leads to changes in excitability of the cortex that outlast the period ofstimulation. Because of this, besides the implications for experimental neuroscientists, there isincreasing interest in the potential for applying either method as a therapy in neurology, psychiatry,rehabilitation, and pain. Given that both techniques lead to the same final result, this article discusses intheory several issues that can help an investigator to decide whether rTMS or tDCS would be moresuitable for the scope of the planned work. 2009 Elsevier Inc..Sobell Department, UCL Institute of Neurology, London, United Kingdomor transcranial direct current
Alberto Prioria, Mark Hallettb, John C. Ro
aDipartimento di Scienze Neurologiche, Universita` degli StuNeurostimolazione, Fondazione IRCCS Ospedale MaggiorebHuman Motor Control Section, National Institute of Neurouary 24, 2009.
-see front matter 2009 Elsevier Inc.s.2009.02.004ic stimulationtimulation?
Milano, Centro Clinico per le Neuronanotecnologie e laclinico, Mangiagalli e Regina Elena, Milano, Italyal Disorders and Stroke, Bethesda, Maryland
www.brainstimjrnl.commental and neurologic disorders.
for the scope of planned work. Of course, both of these
20,000 to 100,000 dollars, tDCS devices are well below
the scalp, so that stimulation occurs in two sites rather
242 A. Priori, M. Hallett, and J.C. Rothwell13,000 dollars (range: 40010,000 dollars). With sucha large difference between the prices, tDCS is clearly themethod of choice where cash is a limitation, at least in ther-apeutic studies.
TMS coils produce a loud click when each stimulus isdelivered; in addition, because electric current is induced inthe scalp as well as the brain, there is usually some activationof local sensory nerves or muscle which is readily perceivedby subjects. Controlling for such effects involves eitherstimulating at some other inactive site on the scalp so thateffects can be ascribed to stimulation of a particular structure,or using a sham coil that gives no stimulation but producesthe same click sound. However, even if the click isindistinguishable from real TMS, lack of induced electriccurrent means that there is no accompanying scalp sensation.It is possible to control for this by including an externalelectrical stimulation under the sham coil that mimics themethods can be used in a variety of ways. rTMS can havevarious patterns of pulses with various intensities, andboth rTMS and tDCS can have various anatomicalplacements. So these issues are addressed in general terms.
Technology and cost
There are a number of practical differences between TMSand tDCS. Although systems for TMS are heavy (severalkilograms) and large, devices for tDCS are light (, 1 kg)and small (less than a shoe box). TMS devices requirea power supplydoften with special featuresdwhereassystems for brain polarization are battery driven and cantherefore be also easily portable. Portability is an importantcharacteristic, and would allow, for example, use of tDCSin the home. There is also a substantial difference in cost:whereas TMS or rTMS systems currently cost betweenProlonged application of either method (eg, severalhundred TMS pulses [rTMS] or several minutes of tDCS)leads to changes in excitability of the cortex that outlast theperiod of stimulation. There is evidence that some of theseeffects are due to changes in synaptic transmission, perhapsresembling long-term plasticity of synapses described inbrain slice preparations.2,3 Because of this, there isincreasing interest in the potential for applying eithermethod as a therapy in neurologic disease or after braininjury. But, given that both techniques lead to the same finalresult, can we consider one better than the other? To decide,unfortunately, there are not yet controlled systematic studiesassessing the two techniques comparatively. We thereforewill discuss several issues that might help an investigatorto decide whether rTMS or tDCS would be more suitablethan one. This issue is not insuperable because one of theelectrodes can be applied extracranially (eg, neck orshoulder). Nevertheless, wherever the electrodes are placed,current flows throughout the brain between the two sites sothat nerve polarization may occur over a wide area. Modelsare being developed that might give some insight into thedistribution of current flow and allow prediction of likelysites of stimulation.
For most therapeutic trials, focality of stimulation is notan issue: in many cases, large areas of cortex are targeted(eg, motor cortex in stroke; dorsolateral prefrontal cortex indepression). In this case, the large sites stimulated withtDCS are no problem. Indeed, tDCS has an advantage overTMS in that it is easy to cut the electrode sponges intodifferent shapes and areas, to tailor stimulation to anindividual brain. This is not possible with TMS unlesssensation experienced during real stimulation.4 However, allthis is at the cost of increasing complexity and cost.
In contrast, tDCS, especially at intensity below 1.5 mA,is generally not perceived by subjects.5 This is particularlytrue if low current intensity is used with large area stimu-lating electrodes (to reduce charge density) and lowimpedance (eg, with saline solution); in such conditionssubjects can be entirely unaware of the difference betweenreal and sham stimulation.6 A second point is thatalthough high-frequency and low-frequency rTMS areobviously different because of the rate of clicks producedby the coil, cathodal and anodal tDCS (that induce oppo-site excitability changes) cannot be discriminated bysubjects and their comparison could therefore be a furthercontrol condition.
Focality of stimulation
Although focality of stimulationdnamely, the spatialresolutiondis a critical issue in the choice of a stimulationtechnique for physiologic experiments, it is probably lessrelevant for current therapeutic applications. TMS coils canbe wound in a variety of different sizes and configurations,and although it is not possible without direct measurementsto be precise, they appear to be able to limit stimulation toan area of about 25 mm2. For example, mapping studies ofmotor cortex before surgery for brain tumors can reliablydistinguish excitable and nonexcitable areas with an accu-racy (compared with direct mapping of exposed cortex) of5 mm or so.
In contrast, tDCS has in the past usually been appliedthrough large electrodes about 2500 mm2 to maintain a lowcurrent density on the scalp (for safety reasons as well asminimal sensation). However, smaller electrodes havebeen used by some authors with some success, althoughthe information on these is limited. A second issue withtDCS is that two electrodes have to be used (and anodeand a cathode), and most authors place both of them on
for the motor, somatosensory and visual cortex, no studies
or otherwise of the stimulus. Although tDCS strength in
ing coil position on the head when subjects can move freely
rTMS or tDCS? 243have investigated differences in electrode placement per-taining to stimulation at other brain sites such as prefrontalcortex.
Specificity of stimulation refers to the ability to targetspecific neural populations and it is important in neuro-physiologic studies. Measures of motor cortical thresholdwith TMS appear to give information about axonalexcitabilit