Advertisement

Consensus Paper: Probing Homeostatic Plasticity of Human Cortex With Non-invasive Transcranial Brain Stimulation

Open AccessPublished:March 31, 2015DOI:https://doi.org/10.1016/j.brs.2015.01.404

      Abstract

      Homeostatic plasticity is thought to stabilize neural activity around a set point within a physiologically reasonable dynamic range. Over the last ten years, a wide range of non-invasive transcranial brain stimulation (NTBS) techniques have been used to probe homeostatic control of cortical plasticity in the intact human brain. Here, we review different NTBS approaches to study homeostatic plasticity on a systems level and relate the findings to both, physiological evidence from in vitro studies and to a theoretical framework of homeostatic function. We highlight differences between homeostatic and other non-homeostatic forms of plasticity and we examine the contribution of sleep in restoring synaptic homeostasis. Finally, we discuss the growing number of studies showing that abnormal homeostatic plasticity may be associated to a range of neuropsychiatric diseases.

      Keywords

      Throughout life the brain flexibly and quickly adapts to environmental changes while at the same time maintaining a relatively stable equilibrium of neural activity over time. At the neural level, synapses can dynamically express lasting changes in synaptic efficacy, long-term potentiation (LTP) or long-term depression (LTD), in response to a change in presynaptic activity [
      • Abbott L.F.
      • Nelson S.B.
      Synaptic plasticity: taming the beast.
      ]. The threshold for induction of LTP and LTD is flexibly adjusted to the level of post-synaptic activity by homeostatic mechanisms [
      • Turrigiano G.G.
      • Nelson S.B.
      Homeostatic plasticity in the developing nervous system.
      ]. These adjustments of plasticity prevent excessive expression of LTP or LTD and keep neural activity within a useful dynamic range [
      • Abraham W.C.
      Metaplasticity: tuning synapses and networks for plasticity.
      ,
      • Hulme S.R.
      • Jones O.D.
      • Abraham W.C.
      Emerging roles of metaplasticity in behaviour and disease.
      ].
      In humans, a range of non-invasive transcranial brain stimulation (NTBS) techniques has been successfully used to induce cortical plasticity [
      • Karabanov A.
      • Ziemann U.
      • Classen J.
      • Siebner H.
      Understanding homeostatic plasticity.
      ,
      • Classen J.
      Plasticity.
      ,
      • Ziemann U.
      • Siebner H.R.
      Modifying motor learning through gating and homeostatic metaplasticity.
      ,
      • Ziemann U.
      • et al.
      Learning modifies subsequent induction of long-term potentiation-like and long-term depression-like plasticity in human motor cortex.
      ]. Research has mainly focused on the motor hand area (M1-Hand) and its fast-conducting descending projections to the contralateral hand because M1-Hand can be easily targeted with NTBS due to its relatively superficial position close to the surface of the convexity of the cerebral hemisphere. Moreover, NTBS-induced corticomotor plasticity can be readily probed by measuring the amplitude of motor evoked potentials (MEP) in contralateral hand muscles, although the mechanism of activating corticospinal neurons is complex and not yet fully understood [
      • Groppa S.
      • et al.
      A practical guide to diagnostic transcranial magnetic stimulation: report of an IFCN committee.
      ]. Several NTBS protocols have been shown to be capable of inducing shifts in corticomotor excitability as indexed by changes in mean MEP amplitude. These changes can outlast the stimulation period for minutes to hours [
      • Siebner H.R.
      • Rothwell J.
      Transcranial magnetic stimulation: new insights into representational cortical plasticity.
      ], yet both, the magnitude and direction of these excitability changes, display substantial inter-individual variability [
      • Pascual-Leone A.
      • et al.
      Responses to rapid-rate transcranial magnetic stimulation of the human motor cortex.
      ,
      • Huang Y.Z.
      • et al.
      Theta burst stimulation of the human motor cortex.
      ,
      • Thickbroom G.W.
      • et al.
      Repetitive paired-pulse TMS at I-wave periodicity markedly increases corticospinal excitability: a new technique for modulating synaptic plasticity.
      ,
      • Stefan K.
      • et al.
      Induction of plasticity in the human motor cortex by paired associative stimulation.
      ,
      • Hamada M.
      • et al.
      Quadro-pulse stimulation is more effective than paired-pulse stimulation for plasticity induction of the human motor cortex.
      ,
      • Nitsche M.A.
      • et al.
      Transcranial direct current stimulation: state of the art 2008.
      ]. Depending on the direction of the amplitude changes, these lasting excitability changes have been labeled as LTP-like or LTD-like effects [
      • Ziemann U.
      • et al.
      Learning modifies subsequent induction of long-term potentiation-like and long-term depression-like plasticity in human motor cortex.
      ]. In analogy to homeostatic metaplasticity at the neuronal level, it has been shown that the LTP- and LTD-like changes are subject to homeostatic control. Here, we review the use of NTBS to non-invasively investigate the homeostatic regulation of regional cortical excitability and relate this line of research to homeostatic plasticity described at the neuronal level in invasive non-human animal studies (Text box 1).
      Definition box

      Metaplasticity: ‘plasticity of synaptic plasticity’

      Metaplasticity is a higher-order form of synaptic plasticity. The term was originally introduced by W.C. Abraham and M.F. Bear [
      • Shouval H.Z.
      • Bear M.F.
      • Cooper L.N.
      A unified model of NMDA receptor-dependent bidirectional synaptic plasticity.
      ]. It refers to synaptic or cellular activity that primes the ability to induce subsequent synaptic plasticity, such as long-term potentiation (LTP) or depression (LTD). The priming event does not necessarily cause a change in the efficacy of normal synaptic transmission. Metaplasticity can be homeostatic or non-homeostatic.

      Homeostatic plasticity: ‘plasticity stabilizing synaptic plasticity’

      The term homeostatic plasticity refers to a range of plasticity mechanisms that stabilize neuronal activity [
      • Hebb D.
      The organization of behavior.
      ]. Homeostatic plasticity counteracts the destabilizing influence of synaptic plasticity and thus, stabilizes neural activity within a physiologically meaningful range.
      Homeostatic mechanisms can be metaplastic or non-metaplastic.

      Basic principles of synaptic plasticity

      The mammalian cortex expresses a wealth of functional and structural mechanisms to change its function in response to experience and use [
      • Feldman D.E.
      Synaptic mechanisms for plasticity in neocortex.
      ]. Functional mechanisms often involve the modification of existing synapses and multiple forms of synaptic plasticity have been demonstrated in vitro and in vivo in excitatory and inhibitory cortical synapses [
      • Sjostrom P.J.
      • et al.
      Dendritic excitability and synaptic plasticity.
      ,
      • Foeller E.
      • Feldman D.E.
      Synaptic basis for developmental plasticity in somatosensory cortex.
      ,
      • Hensch T.K.
      Critical period plasticity in local cortical circuits.
      ]. Synapses can strengthen (LTP) or weaken (LTD) their efficacy (i.e., synaptic strength) in response to increases or decreases in their activity and in accordance with Hebb's famous principle of cell assembly [
      • Lisman J.
      • Lichtman J.W.
      • Sanes J.R.
      LTP: perils and progress.
      ,
      • Malenka R.C.
      • Bear M.F.
      LTP and LTD: an embarrassment of riches.
      ,
      • Turrigiano G.G.
      • Nelson S.B.
      Hebb and homeostasis in neuronal plasticity.
      ,
      • Hebb D.
      The organization of behavior.
      ]. Synaptic plasticity is complemented by other forms of plasticity, including plasticity of intrinsic cellular excitability (Kim & Linden, 2007) and non-Hebbian, homeostatic metaplasticity [
      • Turrigiano G.G.
      • Nelson S.B.
      Homeostatic plasticity in the developing nervous system.
      ,
      • Abraham W.C.
      • Bear M.F.
      Metaplasticity: the plasticity of synaptic plasticity.
      ]. These functional mechanisms go hand in hand with structural plasticity, including the formation, removal, and remodeling of synapses and dendritic spines [
      • Alvarez V.A.
      • Sabatini B.L.
      Anatomical and physiological plasticity of dendritic spines.
      ]. The abundance of plasticity mechanisms in the mammalian neocortex highlights the changeability of cortical neurons. A critical question is how these multiple processes are integrated at the level of a synapse, a single neuron, intracortical microcircuits, and interacting brain systems. The complexity of mechanisms causing synaptic and cellular plasticity renders it difficult to link plasticity-induced change at the regional or system level to specific synaptic or cellular mechanisms. Yet it is likely that plastic processes at the regional or systems level nevertheless follow the same general principles.
      Synaptic plasticity provides a mechanism for learning and enables neurons to dynamically modulate their synaptic strength by relating it to other inputs the cell receives at the same time [
      • Shouval H.Z.
      • Bear M.F.
      • Cooper L.N.
      A unified model of NMDA receptor-dependent bidirectional synaptic plasticity.
      ]. Synaptic plasticity provides an efficient positive feedback mechanism, which enforces (LTP) or weakens (LTD) synaptic transmission [
      • Turrigiano G.G.
      The self-tuning neuron: synaptic scaling of excitatory synapses.
      ]. At many glutamatergic synapses, the magnitude and temporal dynamics of activity-induced Ca2+ influx in the post-synaptic neuron determines whether a given level of presynaptic activity induces LTP or LTD. A fast and large increase in Ca2+ triggers LTP, whereas a moderate but more sustained Ca2+ influx gives rise to LTD [
      • Abbott L.F.
      • Nelson S.B.
      Synaptic plasticity: taming the beast.
      ,
      • Tsumoto T.
      Long-term potentiation and long-term depression in the neocortex.
      ,
      • Lisman J.
      A mechanism for the Hebb and the anti-Hebb processes underlying learning and memory.
      ,
      • Artola A.
      • Singer W.
      Long-term depression of excitatory synaptic transmission and its relationship to long-term potentiation.
      ,
      • Yang S.N.
      • Tang Y.G.
      • Zucker R.S.
      Selective induction of LTP and LTD by postsynaptic [Ca2+]i elevation.
      ]. The existence of distinct thresholds for LTP and LTD induction that are determined by the dynamics of Ca2+ concentrations in the post-synaptic neuron has been nicely illustrated by experiments in rat visual cortex: Artola and coworkers pharmacologically manipulated the level of post-synaptic depolarization by local application of the gamma-aminobutyric acid A (GABAa) receptor antagonist bicuculline. The pharmacological manipulation revealed that the same tetanic stimulation protocol induced either LTP or LTD depending on the level of post-synaptic depolarization: LTD was induced when depolarization exceeded a critical level, but still stayed below the threshold for LTP induction [
      • Artola A.
      • Brocher S.
      • Singer W.
      Different voltage-dependent thresholds for inducing long-term depression and long-term potentiation in slices of rat visual cortex.
      ]. This study showed that the induction and direction of synaptic plasticity depends on the excitability of the post-synaptic neuron at the time of stimulation.

      Homeostatic plasticity (see Table 1)

      The positive feedback nature of synaptic plasticity that allows the ‘rich to get continuously richer’ in the case of LTP and ‘the poor to get poorer’ in the case of LTD [
      • Turrigiano G.G.
      The self-tuning neuron: synaptic scaling of excitatory synapses.
      ] challenges the stability of neural networks [
      • Abbott L.F.
      • Nelson S.B.
      Synaptic plasticity: taming the beast.
      ,
      • Turrigiano G.G.
      • Nelson S.B.
      Homeostatic plasticity in the developing nervous system.
      ,
      • Abraham W.C.
      Metaplasticity: tuning synapses and networks for plasticity.
      ,
      • Turrigiano G.G.
      • Nelson S.B.
      Hebb and homeostasis in neuronal plasticity.
      ]: “Unsupervised” synaptic plasticity has the inherent risk to induce extreme neural states, causing excessive firing (in the case of uncontrolled LTP) or complete silencing of neural activity (in the case of uncontrolled LTD). An extensive body of research has demonstrated that a multitude of regulatory cellular mechanisms counteracts the ‘runaway’ effect of synaptic plasticity. Like LTP and LTD induction many of these mechanisms are triggered by an activity dependent change in intra-cellular Ca2+ levels [
      • Turrigiano G.G.
      • Nelson S.B.
      Homeostatic plasticity in the developing nervous system.
      ,
      • Abraham W.C.
      Metaplasticity: tuning synapses and networks for plasticity.
      ,
      • Turrigiano G.G.
      • Nelson S.B.
      Hebb and homeostasis in neuronal plasticity.
      ,
      • Turrigiano G.G.
      The self-tuning neuron: synaptic scaling of excitatory synapses.
      ,
      • Bear M.F.
      Bidirectional synaptic plasticity: from theory to reality.
      ]. This form of plasticity, commonly referred to as homeostatic plasticity, complements synaptic plasticity and plays a role in stabilizing mean neural activity around a set point within a physiologically reasonable dynamic range.
      Table 1Homeostatic plasticity study results.
      StudyPriming/TestMain findings
      Homeostatic plasticity
       Primary motor cortexSiebner et al. (2004)
      • Todd G.
      • Flavel S.C.
      • Ridding M.C.
      Priming theta-burst repetitive transcranial magnetic stimulation with low- and high-frequency stimulation.
      aTDSC/1Hz rTMS

      cTDCS/1Hz rTMS
      Shows a full homeostatic interaction between priming and an inhibitory test protocol.
      Iyer et al. (2003)
      • Gentner R.
      • et al.
      Depression of human corticospinal excitability induced by magnetic theta-burst stimulation: evidence of rapid polarity-reversing metaplasticity.
      6Hz rTMS/1Hz rTMSThe facilitatory priming increases the LTD-like effect of the 1 Hz test protocol.
      Lang et al. (2004)
      • Gamboa O.L.
      • et al.
      Simply longer is not better: reversal of theta burst after-effect with prolonged stimulation.
      aTDCS/5Hz rTMS

      cTDCS/5Hz rTMS
      One of the first studies to show a full homeostatic interaction between priming and a facilitatory test protocol.
      Muller et al. (2007)
      • Rothkegel H.
      • Sommer M.
      • Paulus W.
      Breaks during 5Hz rTMS are essential for facilitatory after effects.
      PASLTP − PASLTP

      PASLTD − PASLTP
      A PASLTD prime increases the LTP-like effect of the test PASLTP, an PASLTP prime decreases the LTP-like effect of the test PASLTP.
      Nitsche et al. (2007)
      • Fricke K.
      • et al.
      Time course of the induction of homeostatic plasticity generated by repeated transcranial direct current stimulation of the human motor cortex.
      aTDCS/PASLTP

      cTDCS/PASLTP

      either as prime/test or concurrently
      A homeostatic effect was only observed when the protocols where given concurrently when given as a prime/test protocol bith TDCS protocols did increase the facilitatory PAS effect.
      Todd et al. (2009)
      • Karabanov A.
      • Siebner H.R.
      Unravelling homeostatic interactions in inhibitory and excitatory networks in human motor cortex.
      2Hz or 6Hz rTMS/cTBS

      iTBS/cTBS
      The rTMS priming did not affect the cTBS effect, but the iTBS prime did increase the inhibitory effect of cTBS.
      Ni et al. (2014)
      • Di Lazzaro V.
      • Ziemann U.
      • Lemon R.N.
      State of the art: physiology of transcranial motor cortex stimulation.
      cTBS(short)/PASLTP

      cTBS(short)/PASLTD
      The cTBS prime enhanced the PASLTP facilitation and led to reduced SICI and LICI and abolished the PASLTD inhibition without change to intracortical circuits.
      Gentner et al. (2008)
      • Reis J.
      • et al.
      Contribution of transcranial magnetic stimulation to the understanding of cortical mechanisms involved in motor control.
      Muscle activity/cTBS (20 s)

      cTBS 40 s
      Short cTBS did only induce an LTD-like effect when primed by muscle activity, when the protocol is prolonged, no activity prime is needed to induce an LTD.like effect.
      Gamboa et al. (2010)
      • Classen J.
      • et al.
      Integrative visuomotor behavior is associated with interregionally coherent oscillations in the human brain.
      cTBS (double duration)

      iTBS (double duration)
      Both iTBS and cTBS reverse their effect when given for double the standard duration.
      Rothkegel et al. (2010)
      • Rosenkranz K.
      • Kacar A.
      • Rothwell J.C.
      Differential modulation of motor cortical plasticity and excitability in early and late phases of human motor learning.
      5Hz rTMS protocol with or without breaksWhen omitting breaks in a standard 5 Hz protocol the facilitation effect is turned to an inhibition.
      Fricke et al. (2011)
      • Doeltgen S.H.
      • Ridding M.C.
      Low-intensity, short-interval theta burst stimulation modulates excitatory but not inhibitory motor networks.
      aTDCS/aTDCS

      cTDCS/cTDCS

      at different intervals
      When the protocols are given without a break (doubling their length) a prolongation of the ‘test’ effect is seen, when the break is 20 min the protocols do not interact but when given with a 3 min break between test and prime there is a homeostatic interaction.
      Hamada et al. (2008)
      • Buch E.R.
      • et al.
      Noninvasive associative plasticity induction in a corticocortical pathway of the human brain.
      QPS/QPSHigh-freq. QPS priming causes a homeostatic rightward shift of the LTD/LTP induction curve. Low-freq. QPS priming induces the opposite effect (homeostatic leftward shift of the LTP-LTD induction curve).
       Intracortical networksDoeltgen et al. (2011)
      • Bocci T.
      • et al.
      Evidence for metaplasticity in the human visual cortex.
      iTBS/cTBSNo effect of priming on SICI and SICF.
      Fricke et al. (2011)
      • Doeltgen S.H.
      • Ridding M.C.
      Low-intensity, short-interval theta burst stimulation modulates excitatory but not inhibitory motor networks.
      aTDCS/aTDCS

      cTDCS/cTDCS

      at different intervals
      No effect of priming on SICI and SICF.
      Siebner et al. (2004)
      • Todd G.
      • Flavel S.C.
      • Ridding M.C.
      Priming theta-burst repetitive transcranial magnetic stimulation with low- and high-frequency stimulation.
      aTDCS or cTDCS/1Hz rTMSNo effect of priming on SICI and SICF.
      Murakami et al. (2012)
      • Lepage J.F.
      • et al.
      Occlusion of LTP-like plasticity in human primary motor cortex by action observation.
      cTBS/cTBS

      iTBS/iTBS

      cTBS/iTBS

      iTBS/cTBS
      SICI is only altered when prime and test protocol are identical.
       Interregional cortical networks and outside M1Potter-Nerger et al. (2009)
      • Cantarero G.
      • Lloyd A.
      • Celnik P.
      Reversal of long-term potentiation-like plasticity processes after motor learning disrupts skill retention.
      1Hz rTMS/PASLTD

      5Hz rTMS/PASLTP
      1Hz rTMS to the dPMC prior to a PASLTD protocol over M1 increases M1 excitability.

      5Hz rTMS to the dPMC prior to a PASLTP protocol over M1 suppressed M1 excitability.
      Hamada et al. (2009)
      • Hess G.
      • Aizenman C.D.
      • Donoghue J.P.
      Conditions for the induction of long-term potentiation in layer II/III horizontal connections of the rat motor cortex.
      QPS/QPS

      1Hz rTMS/
      Homeostatic modulation of M1 excitability when a priming QPS prime is given to the SMA
      Ragert et al. (2009)
      • Cantarero G.
      • et al.
      Motor learning interference is proportional to occlusion of LTP-like plasticity.
      1Hz rTMS/iTBSHomeostatic modulation of M1 excitability when a priming rTMS prime is given to the contralateral M1.
      Bliem et al. (2008)
      • Jung P.
      • Ziemann U.
      Homeostatic and nonhomeostatic modulation of learning in human motor cortex.
      PAS/20Hz HFSHomeostatic plasticity in primary sensorimotor cortex.
      Gartic a Tossi et al. (2014)
      • Teo J.T.
      • et al.
      Human theta burst stimulation enhances subsequent motor learning and increases performance variability.
      5Hz rTMS/20Hz HFSHomeostatic plasticity in primary sensorimotor cortex.
      Bocci et al. (2014)
      • Kuo M.F.
      • et al.
      Limited impact of homeostatic plasticity on motor learning in humans.
      TDCS/rTMSHomeostatic plasticity in primary visual cortex.
      Interaction of Motor learning and homeostatic plasticityZiehmann al. (2004)
      • Ziemann U.
      • et al.
      Learning modifies subsequent induction of long-term potentiation-like and long-term depression-like plasticity in human motor cortex.
      Thumb abduction/PASLTP

      Thumb abduction/PASLTD
      Motor learning can act as a priming intervention for subsequent NIBS and induce homeostatic effects.
      Lepage et al. (2012)
      • Antal A.
      • et al.
      Facilitation of visuo-motor learning by transcranial direct current stimulation of the motor and extrastriate visual areas in humans.
      Motor observation/PASLTPObservation of a motor training task is sufficient to prevent subsequent induction of LTP-like PAS effects.
      Rosenkranz et al. (2007)
      • Gatica Tossi M.A.
      • et al.
      Behavioural and neurophysiological markers reveal differential sensitivity to homeostatic interactions between centrally and peripherally applied passive stimulation.
      Novel vs. well-practiced thumb abduction/PASThe effect of motor learning as a ‘primer’ depends on the learning phase: homeostatic effects only observed when ‘priming’ involved a novel motor task.
      Elahi et al. (2014)
      • Schambra H.M.
      • et al.
      Probing for hemispheric specialization for motor skill learning: a transcranial direct current stimulation study.
      PAS/thumb abductionNIBS can act as a primer on motor learning.
      Jung et al. (2009)
      • Stagg C.J.
      • et al.
      Polarity and timing-dependent effects of transcranial direct current stimulation in explicit motor learning.
      PASLTD/thumb abduction task

      PASLTP/thumb abduction task
      PAS given 90 min before the learning task shows a “classic” homeostatic interaction, when given directly before the task both PASLTP and PASLTD facilitate learning.
      Teo et al. (2011)
      • Delvendahl I.
      • et al.
      Occlusion of bidirectional plasticity by preceding low-frequency stimulation in the human motor cortex.
      iBTS/thumb abductionPriming with iTBS boosts performance in a subsequent ballistic motor learning task. The effect of priming iBTS can be blocked by nicotine administration.
      Kuo et al. (2008)
      • Siebner H.R.
      A primer on priming the human motor cortex.
      TDCS/serial reaction time taskNo homeostatic effect between TDCS and motor learning found.
      Rosenkranz et al. (2014)
      • Wankerl K.
      • et al.
      L-type voltage-gated Ca2+ channels: a single molecular switch for long-term potentiation/long-term depression-like plasticity and activity-dependent metaplasticity in humans.
      Hand immobilization/PASEight hours of hand immobilization significantly reduce the inhibitory effects of PAS-10ms while enhancing the facilitatory effects of PAS-25ms.
      Non-homeostatic plasticityNitsche et al. (2003)
      • Larson J.
      • Xiao P.
      • Lynch G.
      Reversal of LTP by theta frequency stimulation.


      Anatal et al. (2004)
      • Kulla A.
      • Manahan-Vaughan D.
      Depotentiation in the dentate gyrus of freely moving rats is modulated by D1/D5 dopamine receptors.


      Reis & Fritsch (2011)
      • Huang Y.Z.
      • et al.
      Reversal of plasticity-like effects in the human motor cortex.


      Stagg et al. (2011)
      • Hulme S.R.
      • et al.
      Calcium-dependent but action potential-independent BCM-like metaplasticity in the hippocampus.
      Concurrent motor learning and TDCS‘Gating’: Studies have reported reinforcing effects between voluntary motor activity and TDCS when applied concurrently.
      Devendahl et al. (2010)
      • Pozo K.
      • Goda Y.
      Unraveling mechanisms of homeostatic synaptic plasticity.
      0.1Hz rTMS/PAS‘Anti-gating’: A very low-frequency prime abolished the ability to induce LTP- and LTD-like with subsequent PAS
      Huang et al. (2010)
      • Lioumis P.
      • et al.
      Reproducibility of TMS-evoked EEG responses.
      iTBS/cTBS

      cTBS/iTBS
      The LTP-like effect induced by iTBS is abolished (de-potentiated), when a short train of cTBS followed the protocol.

      The LTD-like effect induced by cTBS is abolished (de-depressed), if followed by a short train of iTBS.
      Ni et al. (2014)
      • Di Lazzaro V.
      • Ziemann U.
      • Lemon R.N.
      State of the art: physiology of transcranial motor cortex stimulation.
      PASLTP/cTBS(short)

      PASLTD/cTBS(short)
      De-potentiating effect of a short inhibitory follow-up.
      Goldsworthy et al. (2014)
      • Casarotto S.
      • et al.
      EEG responses to TMS are sensitive to changes in the perturbation parameters and repeatable over time.
      cTBS/voluntary contractionDe-depressing effect on a short facilitatory follow up on an inhibitory protocol.
      Cantarero et al. (2013)
      • Reis J.
      • et al.
      Noninvasive cortical stimulation enhances motor skill acquisition over multiple days through an effect on consolidation.


      Cantarero et al. (2013)
      • Reis J.
      • Fritsch B.
      Modulation of motor performance and motor learning by transcranial direct current stimulation.
      Motor learning task/cTBSOcclusion of LTP –like effect and motor skill retention after short inhibitory protocol.
      Lepage et al. (2012)
      • Antal A.
      • et al.
      Facilitation of visuo-motor learning by transcranial direct current stimulation of the motor and extrastriate visual areas in humans.
      Motor observation/PASLTPObservation of a motor training task is sufficient to prevent subsequent induction of LTP-like PAS effects.
      Homeostatic plasticity in pathological states
       Focal hand dystoniaQuartarone et al. (2005)
      • Stefansson H.
      • et al.
      Association of neuregulin 1 with schizophrenia confirmed in a Scottish population.
      TDCS/1Hz rTMSThe ‘homeostatic’ response pattern of healthy controls is absent in the affected hand of writer's cramp patients.
      Kang et al. (2011)
      • Duman R.S.
      • Aghajanian G.K.
      Synaptic dysfunction in depression: potential therapeutic targets.
      PASLTP – thumb abduction

      PASLTD – thumb abduction
      In contrast to healthy controls the writer's cramp patients do not show any modulation of learning-dependent plasticity.
       Parkinson's diseaseHuang et al. (2011) [151]TBSPatients with levodopa-induced dyskinesia showed normal potentiation but were unresponsive to the de-potentiation protocol.
      Net neuronal excitability depends on the interaction between intrinsic firing properties of the neuron and synaptic inputs. Therefore, homeostatic plasticity can be achieved by two fundamentally different mechanisms: synaptic homeostasis regulates excitability by up- or down-regulating synaptic strength, whereas intrinsic homeostasis shifts the relationship between synaptic input and firing by controlling intrinsic excitability [
      • Turrigiano G.G.
      The self-tuning neuron: synaptic scaling of excitatory synapses.
      ] (Fig. 1). Even though there is ample evidence that both mechanisms coexist, it is not completely clear to what extent they serve different functions in stabilizing neural circuits and how particular firing patterns or activity levels call the appropriate homeostatic mechanism into action [
      • Turrigiano G.
      Too many cooks? Intrinsic and synaptic homeostatic mechanisms in cortical circuit refinement.
      ,
      • Turrigiano G.
      Homeostatic synaptic plasticity: local and global mechanisms for stabilizing neuronal function.
      ,
      • Nelson S.B.
      • Turrigiano G.G.
      Strength through diversity.
      ].
      Figure thumbnail gr1
      Figure 1Figure shows two essentially different mechanisms for the homeostatic regulation. (A) Neuronal activity is governed by both the balance of voltage-gated sodium (Na+) and potassium (K+) channels regulating intrinsic excitability and the weight of excitatory and inhibitory synapses. Neurons react to prolonged sensory deprivation either by increasing the weight of excitatory inputs (synaptic homeostasis) (B) or by increasing the amount of inward voltage-dependent currents (intrinsic homeostasis) (C) whereas they react to prolonged sensory activity by increasing the weight of inhibitory inputs (synaptic homeostasis) (D) or by increasing the amount of outward voltage-dependent currents (intrinsic homeostasis) (E).

      A theoretical model for homeostatic plasticity

      Over 30 years ago Bienenstock, Cooper and Munro proposed a theory of how Hebbian plasticity is homeostatically regulated depending on experience-dependent modifications in post-synaptic neuronal activity. The Bienenstock–Cooper–Munro (BCM) theory postulates a “sliding threshold” for bidirectional synaptic plasticity [
      • Cooper L.N.
      • Bear M.F.
      The BCM theory of synapse modification at 30: interaction of theory with experiment.
      ,
      • Bienenstock E.L.
      • Cooper L.N.
      • Munro P.W.
      Theory for the development of neuron selectivity: orientation specificity and binocular interaction in visual cortex.
      ], predicting that the thresholds for induction of LTP and LTD are dynamically adjusted to the integrated level of previous post-synaptic activity. According to the BCM theory, a history of low post-synaptic activity will lower the synaptic modification threshold for future LTP induction and increase the threshold for LTD. Conversely, a history of high synaptic activity will shift the modification threshold favoring the induction of LTD and increase the threshold for LTP (Fig. 2A). The BCM theory has become the most influential model of heterosynaptic homeostatic plasticity and has guided experimental work throughout the last three decades. Even though the BCM theory was first introduced to account for experimental observations in the visual cortex, evidence for a ‘sliding threshold’ regulating the range of synaptic modification has been obtained in numerous animal and human experiments [
      • Kirkwood A.
      • Rioult M.C.
      • Bear M.F.
      Experience-dependent modification of synaptic plasticity in visual cortex.
      ,
      • Wang H.
      • Wagner J.J.
      Priming-induced shift in synaptic plasticity in the rat hippocampus.
      ,
      • Hamada M.
      • et al.
      Primary motor cortical metaplasticity induced by priming over the supplementary motor area.
      ,
      • Hamada M.
      • Ugawa Y.
      Quadripulse stimulation–a new patterned rTMS.
      ] and the rule of a ‘sliding threshold’ has been established as a key feature of homeostatic plasticity in many brain regions [
      • Cooper L.N.
      • Bear M.F.
      The BCM theory of synapse modification at 30: interaction of theory with experiment.
      ].
      Figure thumbnail gr2
      Figure 2Figure shows the bidirectional shift of the LTP–LTD induction curve predicted by the BCM theory (A) and induced by a priming QPS session (B). (A) The LTD–LTP crossover point (θM) slides to the right on the x-axis if the preceding neuronal activity is high (θM′), and to the left if preceding activity is low (θM″). (B) QPS with priming over M1. The normalized amplitudes of MEP at 30 min post conditioning as a function of the reciprocal of ISI of QPS (in Hertz) with and without priming over M1. QPS-5 ms priming over M1 resulted in a rightward shift, whereas QPS-50 ms priming produced a leftward shift of the “LTP-LTD induction curve”. The x-axis is logarithmically scaled.
      (Reprinted from Hamada, M. and Ugawa, Y. Restor Neurol Neurosci, 2010;28:419. With permission from IOS Press and the original authors.)
      The threshold for LTP and LTD induction is also homeostatically modulated under physiological conditions [
      • Hess G.
      • Aizenman C.D.
      • Donoghue J.P.
      Conditions for the induction of long-term potentiation in layer II/III horizontal connections of the rat motor cortex.
      ,
      • Castro-Alamancos M.A.
      • Donoghue J.P.
      • Connors B.W.
      Different forms of synaptic plasticity in somatosensory and motor areas of the neocortex.
      ]. A seminal study by Rioult-Pedotti et al. (2000) showed that motor skill learning shares common mechanisms with LTP: when rats had been trained for 5 days on a skilled reaching task, the trained M1 expressed less LTP and more LTD as opposed to the untrained M1 of control rats [
      • Rioult-Pedotti M.S.
      • Friedman D.
      • Donoghue J.P.
      Learning-induced LTP in neocortex.
      ]. This finding shows that the ability to induce LTP and LTD is homeostatically adjusted by previous learning experience, rendering the induction of LTP more difficult after intensive training.

      Approaches to study plasticity in the intact human cortex

      The basic mechanisms of plasticity have been primarily investigated in vitro. In slice preparations, LTD or LTP are commonly induced by repeated tetanic stimulation of the presynaptic neuron: at many sites, low-frequency stimulation (1–3 Hz) leads to LTD [
      • Massey P.V.
      • Bashir Z.I.
      Long-term depression: multiple forms and implications for brain function.
      ] whereas trains of high-frequency stimulation elicit LTP (≥20 Hz) [
      • Cooke S.F.
      • Bliss T.V.
      Plasticity in the human central nervous system.
      ]. However, these in vitro studies need to be complemented by in vivo studies in animals and humans to probe the functional relevance of synaptic and homeostatic plasticity. This motivates the use of non-invasive brain stimulation (NTBS) to study plasticity in the intact human cortex.
      A range of NTBS protocols have been established over the years to study cortical plasticity [
      • Ziemann U.
      • Siebner H.R.
      Modifying motor learning through gating and homeostatic metaplasticity.
      ]. Using stimulation parameters similar to those found effective in slice preparations, both LTP and LTD-like effects can be observed in the intact human brain [
      • Classen J.
      Plasticity.
      ,
      • Sharma N.
      • Classen J.
      • Cohen L.G.
      Neural plasticity and its contribution to functional recovery.
      ]. NTBS-induced plasticity is commonly tested in the fast-conducting corticospinal projections by applying NTBS to the primary motor cortex (M1). The plasticity is usually probed by measuring the mean amplitude of the motor evoked potential (MEP) with single-pulse transcranial magnetic stimulation (TMS) at constant stimulus intensity before and several times after application of the plasticity-inducing NTBS protocol. Serial measurements of mean MEP amplitude offer a feasible and quantitative way to test changes in excitability levels of the corticomotor output pathway. However, it should be noted that the MEP represents a complex composite measure and its amplitude is influenced by multiple physiological factors including the excitability of neural circuits at both the cortical and spinal level [
      • Groppa S.
      • et al.
      A practical guide to diagnostic transcranial magnetic stimulation: report of an IFCN committee.
      ]. For instance, a change in mean MEP amplitude while keeping TMS intensity constant might simply be caused by a more synchronous muscle excitation without necessarily changing the number of activated corticospinal motoneurons. Finally, MEP measurements before and after a plasticity-inducing NTBS protocol restrict the investigation of cortical plasticity to the M1 and any extrapolation of the observed plasticity patterns to other cortical areas need to be made with great caution.
      When applying regular trains of repetitive TMS (rTMS), high-frequency rTMS using frequencies of 5 Hz or higher [
      • Takano B.
      • et al.
      Short-term modulation of regional excitability and blood flow in human motor cortex following rapid-rate transcranial magnetic stimulation.
      ] increase excitability in the stimulated M1 [
      • Ziemann U.
      • Siebner H.R.
      Modifying motor learning through gating and homeostatic metaplasticity.
      ,
      • Quartarone A.
      • Siebner H.R.
      • Rothwell J.C.
      Task-specific hand dystonia: can too much plasticity be bad for you?.
      ,
      • Hallett M.
      Transcranial magnetic stimulation: a primer.
      ], while low-frequency rTMS at a frequency of around 1 Hz (Chen et al., 1997) decrease corticomotor excitability. Patterned rTMS protocols consist of short high-frequency bursts separated by longer inter-burst intervals. They are inspired by patterned burst stimulation protocols applied in cortical slices to induce LTP or LTD [
      • Huang Y.Z.
      • et al.
      Theta burst stimulation of the human motor cortex.
      ,
      • Hess G.
      • Aizenman C.D.
      • Donoghue J.P.
      Conditions for the induction of long-term potentiation in layer II/III horizontal connections of the rat motor cortex.
      ]. Two patterned rTMS protocols have been established, called theta-burst stimulation (TBS) [
      • Huang Y.Z.
      • et al.
      Theta burst stimulation of the human motor cortex.
      ,
      • Hamada M.
      • et al.
      Quadro-pulse stimulation is more effective than paired-pulse stimulation for plasticity induction of the human motor cortex.
      ,
      • Nyffeler T.
      • et al.
      Extending lifetime of plastic changes in the human brain.
      ] and quadripulse stimulation [
      • Huang Y.Z.
      • et al.
      Theta burst stimulation of the human motor cortex.
      ,
      • Hamada M.
      • et al.
      Quadro-pulse stimulation is more effective than paired-pulse stimulation for plasticity induction of the human motor cortex.
      ]. The most commonly used TBS protocol applies 50 Hz bursts consisting of three TMS pulses at a burst repetition rate of 5 Hz. TBS of M1 induces generally a lasting increase in MEP amplitude when given intermittently (i.e., iTBS), while continuous theta-burst stimulation (cTBS) induced a lasting reduction in MEP amplitude. Quadripulse stimulation (QPS) applies four-pulse bursts at a lower repetition rate than TBS, namely at 0.2 Hz. QPS of M1 at very short inter-stimulus intervals (1.5–10 ms, QPSshort) has been shown to increase mean MEP amplitude while QPS of M1 at inter-stimulus intervals of ≥30 ms (QPSlong) decreases MEP amplitude [
      • Hamada M.
      • et al.
      Bidirectional long-term motor cortical plasticity and metaplasticity induced by quadripulse transcranial magnetic stimulation.
      ].
      Other TMS protocols employ associative stimulation of two neural substrates in a temporally coordinated manner. These paired association stimulation (PAS) protocols use a temporal learning rule in analogy to spike-timing dependent plasticity (STDP). For STDP, the direction of plasticity (LTP or LTD induction) depends on the precise timing of pre- and post-synaptic stimulation. The classic PAS protocol pairs peripheral electrical stimulation with single-pulse TMS of contralateral M1 and repeats these stimulus pairs at a low frequency of 0.1 Hz [
      • Stefan K.
      • et al.
      Induction of plasticity in the human motor cortex by paired associative stimulation.
      ,
      • Classen J.
      • et al.
      Paired associative stimulation.
      ,
      • Rizzo V.
      • et al.
      Paired associative stimulation of left and right human motor cortex shapes interhemispheric motor inhibition based on a Hebbian mechanism.
      ,
      • Chao C.C.
      • et al.
      Induction of motor associative plasticity in the posterior parietal cortex-primary motor network.
      ]. More recent cortico-cortical PAS protocols use dual-site TMS targeting two cortical areas [
      • Rizzo V.
      • et al.
      Paired associative stimulation of left and right human motor cortex shapes interhemispheric motor inhibition based on a Hebbian mechanism.
      ,
      • Chao C.C.
      • et al.
      Induction of motor associative plasticity in the posterior parietal cortex-primary motor network.
      ,
      • Arai N.
      • et al.
      State-dependent and timing-dependent bidirectional associative plasticity in the human SMA-M1 network.
      ,
      • Buch E.R.
      • et al.
      Noninvasive associative plasticity induction in a corticocortical pathway of the human brain.
      ]. Corticomotor excitability increases after classical PAS, if the afferent stimulus reaches M1 before or at the same time as TMS-induced M1 stimulation. Conversely, corticomotor excitability is reduced, if the afferent stimulation reaches M1 after excitation by TMS.
      Also, transcranial direct current stimulation (TDCS) can be used to induce lasting bidirectional excitability changes in the human cortex. By applying a constant low current via small electrodes TDCS can either de- or hyperpolarize a neuron's resting membrane potential: anodal TDCS (aTDCS) is thought to depolarize neurons and thereby increases corticomotor excitability, whereas cathodal tDCS (cTDCS) hyperpolarizes the resting membrane, causing a decreased corticomotor excitability [
      • Nitsche M.A.
      • et al.
      Transcranial direct current stimulation: state of the art 2008.
      ].
      For some but not all of these protocols, it has been shown that changes in MEP amplitude after NTBS of M1 display some features that are reminiscent of LTP or LTD at the synaptic level. The modulation of excitability outlasts stimulation time by at least 30 min, depends on NMDA receptor activity, and originates not from subcortical or spinal excitability changes but from a cortical level [
      • Ziemann U.
      • Siebner H.R.
      Modifying motor learning through gating and homeostatic metaplasticity.
      ,
      • Quartarone A.
      • Siebner H.R.
      • Rothwell J.C.
      Task-specific hand dystonia: can too much plasticity be bad for you?.
      ,
      • Hallett M.
      Transcranial magnetic stimulation: a primer.
      ]. Therefore the lasting increases or decreases in corticomotor excitability are often called ‘LTP-like’ or ‘LTD-like’ plasticity. It is important to note though that despite the resemblance between NTBS-induced ‘LTP-like’ or ‘LTD-like’ effects and synaptic LTP or LTD, there are apparent differences: TMS activates a substantial number of axons and leads to a massive stimulation of both inhibitory and excitatory cells, whereas synaptic activity is limited to a very small number of connections in classical in vitro studies of LTP and LTD [
      • Funke K.
      • Benali A.
      Modulation of cortical inhibition by rTMS – findings obtained from animal models.
      ,
      • Pell G.S.
      • Roth Y.
      • Zangen A.
      Modulation of cortical excitability induced by repetitive transcranial magnetic stimulation: influence of timing and geometrical parameters and underlying mechanisms.
      ]. Therefore, NTBS-induced plasticity is likely a mixture of plasticity induction in a number of different sets of excitatory and inhibitory synapses. Indeed, a simple equalization of synaptic effects and the NTBS induced after effects is certainly an oversimplification [
      • Carson R.G.
      • Kennedy N.C.
      Modulation of human corticospinal excitability by paired associative stimulation.
      ]. This is why, in the following text, the terms “inhibitory” (LTD-like) or “facilitatory” (LTP-like) are only describing the final outcome of a protocol on cortical excitability. In fact, a “facilitatory” protocol could be caused by a decrease in inhibition instead of up-regulated excitation. Another important point to note is that the knowledge about LTP- and LTD-like effects is nearly exclusively based on NTBS studies targeting M1 and these effects cannot be easily extrapolated to other cortical areas.

      Testing homeostatic plasticity with NTBS targeting human M1

      The BCM theory predicts that high levels of prior activity favor the induction of LTD, while low levels of prior activity favor LTP [
      • Ziemann U.
      • et al.
      Consensus: motor cortex plasticity protocols.
      ]. In the human M1, homeostatic patterns have been tested using a priming – test design, which consists of a “priming” NTBS protocol that triggers a homeostatic response and a “test” NTBS protocol that captures the homeostatic response (for recent review, see Ref. [
      • Muller-Dahlhaus F.
      • Ziemann U.
      Metaplasticity in human cortex.
      ]). The first study that showed bidirectional homeostatic-like plasticity in M1 combined a TDCS protocol to prime the subsequent response of M1 to a 1Hz rTMS test protocol: In separate sessions, facilitatory aTDCS, inhibitory cTDCS, or sham stimulation were applied prior to a 15 min treatment session of low-intensity 1Hz TMS. After a facilitatory aTDCS priming session, the subsequent 1Hz rTMS test session had a marked LTD-like effect, causing a reduction in corticomotor excitability. Conversely, inhibitory priming with cTDCS flipped the effect of the very same 1Hz rTMS test session, which now produced an increase in corticomotor excitability. When preconditioned by sham TDCS, the 1 Hz protocol did not have an effect on corticomotor excitability [
      • Siebner H.R.
      • et al.
      Preconditioning of low-frequency repetitive transcranial magnetic stimulation with transcranial direct current stimulation: evidence for homeostatic plasticity in the human motor cortex.
      ]. This bidirectional modulation of the subsequent 1Hz rTMS session by the polarity of TDCS strongly suggests that TDCS triggered a homeostatic mechanism in the primed M1 according to the BCM theory. The observation that in the same individual the same NTBS protocol caused either LTP- or LTD-like effects depending on the history of neural activity (manipulated by TDCS priming) questions the validity of a rigid distinction in “facilitatory” or “inhibitory” NTBS protocols, as if these attributes were stable for a given NTBS protocol and robust against the physiological context.
      Many other studies have reported similar homeostatic ‘priming’ effects on the plasticity-inducing properties of various NTBS protocols [
      • Iyer M.B.
      • Schleper N.
      • Wassermann E.M.
      Priming stimulation enhances the depressant effect of low-frequency repetitive transcranial magnetic stimulation.
      ,
      • Lang N.
      • et al.
      Preconditioning with transcranial direct current stimulation sensitizes the motor cortex to rapid-rate transcranial magnetic stimulation and controls the direction of after-effects.
      ,
      • Muller J.F.
      • et al.
      Homeostatic plasticity in human motor cortex demonstrated by two consecutive sessions of paired associative stimulation.
      ,
      • Nitsche M.A.
      • et al.
      Timing-dependent modulation of associative plasticity by general network excitability in the human motor cortex.
      ,
      • Todd G.
      • Flavel S.C.
      • Ridding M.C.
      Priming theta-burst repetitive transcranial magnetic stimulation with low- and high-frequency stimulation.
      ]. The homeostatic pattern that emerged in these studies showed that the priming NTBS would boost the effect of subsequent test NTBS protocol only if the priming NTBS induced the opposite effect on excitability as the test NTBS. Conversely, the priming NTBS would weaken or reverse the effect of subsequent test NTBS, if it had the same effect on excitability as the test NTBS (Fig. 3). A homeostatic reversal of the excitability effect has also been observed when the same NTBS protocol was applied consecutively [
      • Muller J.F.
      • et al.
      Homeostatic plasticity in human motor cortex demonstrated by two consecutive sessions of paired associative stimulation.
      ], when two NTBS protocols were applied simultaneously (Nitsche et al., 2007), when doubling the duration of stimulation [
      • Gentner R.
      • et al.
      Depression of human corticospinal excitability induced by magnetic theta-burst stimulation: evidence of rapid polarity-reversing metaplasticity.
      ,
      • Gamboa O.L.
      • et al.
      Simply longer is not better: reversal of theta burst after-effect with prolonged stimulation.
      ] or when omitting breaks in the stimulation [
      • Rothkegel H.
      • Sommer M.
      • Paulus W.
      Breaks during 5Hz rTMS are essential for facilitatory after effects.
      ].
      Figure thumbnail gr3
      Figure 3Figure shows the basic concept of metaplasticity following the BCM theory. The modification threshold (θM), the crossover point from LTD to LTP, is not fixed but varies as a function of post-synaptic activity. Using an LTP-like prime will shift the modification threshold (θM″) to the right along the x-axis, while using an LTD-like prime will shift the modification threshold (θM′) to the left on the x-axis. On the color bar, red codes an LTD response while blue codes an LTP response. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
      These experiments point to the importance of the interval between priming and test NTBS. Within the framework of the BMC theory, this implies that the temporal dynamics of the primed change in post-synaptic neural activity is critical to shift the sliding threshold in a homeostatic fashion. Yet only one study has tried to systematically investigate the time dependency of homeostatic plasticity by systematically varying the interval between priming and test NTBS and assess the impact of this manipulation on the induction of a homeostatic response [
      • Fricke K.
      • et al.
      Time course of the induction of homeostatic plasticity generated by repeated transcranial direct current stimulation of the human motor cortex.
      ]. Fricke and coworkers (2011) paired two identical 5 min sessions of TDCS. Priming and test TDCS sessions were separated by 0, 3 or 30 min. When priming and test TDCS were given without a break, the TDCS effect was simply prolonged. If the two TDCS sessions were separated by 30 min, there was no priming effect on the plasticity-inducing effect of the test TDCS. Only when the test TDCS started 3 min after the end of priming TDCS, did the two TDCS protocols interact in a homeostatic fashion. This study stresses that there might be a critical time window during which a homeostatic response pattern might emerge after priming NTBS. Yet it is important to bear in mind that this critical time window may differ among different priming NTBS protocols.
      A relatively new TMS protocol that has proven to be especially helpful for investigating homeostatic effects in M1 is quadruple-pulse stimulation (QPS). QPS induces changes in corticomotor excitability by applying trains of four-pulse bursts with an inter-burst interval of 5 s [
      • Hamada M.
      • et al.
      Bidirectional long-term motor cortical plasticity and metaplasticity induced by quadripulse transcranial magnetic stimulation.
      ]. Depending on the ISI that separates the four pulses, QPS induces either an LTP-like increase in corticomotor excitability or an LTD-like decrease in corticomotor excitability. An “LTP-LTD induction curve” can be derived by plotting the LTP- or LTD-like effects of the QPS (x-axis) against the frequency of the four-pulse burst [
      • Hamada M.
      • et al.
      Quadro-pulse stimulation is more effective than paired-pulse stimulation for plasticity induction of the human motor cortex.
      ]. Hamada et al. (2008) showed that this LTP-LTD induction curve can be bi-directionally shifted by a priming QPS protocol (Fig. 2B): A priming QPS with an LTP-inducing high-frequency burst (i.e., QPS with a short ISI of 5 ms) switches the “normal” LTP-like effect of most QPS protocols with short ISIs into an LTD-like effect. An LTP-like effect only persisted for the test QPS protocols with the shortest ISIs. In other words, the priming QPS caused a homeostatic rightward shift of the LTD/LTP induction curve. The opposite effect was produced when an LTD-inducing QPS prime with a low-frequency burst (i.e., QPS with a long ISI of 50 ms) was used. In this case, priming QPS switched the “normal” LTD-like effect of most QPS protocols with long ISIs into an LTP-like effect, causing a homeostatic leftward shift of the LTP-LTD induction curve. The bidirectional shifts in the LTP-LTD induction curve nicely demonstrated the existence of a “sliding modification threshold” as predicted by the BMC theory [
      • Hamada M.
      • Ugawa Y.
      Quadripulse stimulation–a new patterned rTMS.
      ].

      Homeostatic plasticity in cortical networks

      Intracortical homeostatic plasticity in the motor cortex

      The MEP is a complex measure of corticospinal excitability and is influenced by spinal excitability as well as by various intracortical circuits projecting onto the corticospinal motor neurons [
      • Groppa S.
      • et al.
      A practical guide to diagnostic transcranial magnetic stimulation: report of an IFCN committee.
      ,
      • Karabanov A.
      • Siebner H.R.
      Unravelling homeostatic interactions in inhibitory and excitatory networks in human motor cortex.
      ,
      • Di Lazzaro V.
      • Ziemann U.
      • Lemon R.N.
      State of the art: physiology of transcranial motor cortex stimulation.
      ]. This means that homeostatic plasticity might not only affect corticospinal neurons directly but might also act on intracortical circuits within M1.
      Intracortical excitability can be measured by using paired-pulse TMS paradigms, which apply a conditioning (CS) and test stimulus (TS) through the same coil [
      • Reis J.
      • et al.
      Contribution of transcranial magnetic stimulation to the understanding of cortical mechanisms involved in motor control.
      ]. While several studies have shown motor-training induced plasticity of these intracortical inhibitory circuits [
      • Classen J.
      • et al.
      Integrative visuomotor behavior is associated with interregionally coherent oscillations in the human brain.
      ,
      • Rosenkranz K.
      • Kacar A.
      • Rothwell J.C.
      Differential modulation of motor cortical plasticity and excitability in early and late phases of human motor learning.
      ], very few studies have investigated homeostatic effects in intracortical circuits. The results of these studies are not yet fully conclusive: Siebner (2004), Fricke (2011) and Doeltgen [
      • Doeltgen S.H.
      • Ridding M.C.
      Low-intensity, short-interval theta burst stimulation modulates excitatory but not inhibitory motor networks.
      ] found no consistent homeostatic changes in intracortical inhibitory GABAAergic circuits in M1 underlying short interval intracortical inhibition (SICI) [
      • Kujirai T.
      • et al.
      Corticocortical inhibition in human motor cortex.
      ]. A more systematic investigation of homeostatic effects in intracortical inhibitory circuits demonstrated homeostatic plasticity-like effects on SICI: Murakami and colleagues [
      • Murakami T.
      • et al.
      Homeostatic metaplasticity of corticospinal excitatory and intracortical inhibitory neural circuits in human motor cortex.
      ] applied ‘facilitatory’ intermittent theta-burst stimulation (iTBS) or ‘inhibitory’ continuous theta-burst stimulation (cTBS) to induce a homeostatic response in intracortical inhibitory circuits. They found that a priming TBS protocol altered the responsiveness of the inhibitory SICI circuits to a test TBS only when the second TBS protocol was identical to the priming protocol (iTBS → iTBS or cTBS → cTBS). The normal direction of TBS-induced SICI after-effects was reversed by priming with identical TBS, suggesting homeostatic regulation of excitability in inhibitory circuits. However, even in that study homeostatic metaplasticity was less consistently expressed in the intracortical inhibitory circuits than in the excitatory corticospinal pathway. In contrast to homeostasis in the corticospinal pathway alternating TBS protocols (the iTBS → cTBS or cTBS → iTBS) failed to trigger a homeostatic response in inhibitory circuits.
      Facilitatory circuits within M1 have been even more sparsely studied than intracortical inhibition and no consistent homeostatic effects have been demonstrated so far on intracortical facilitation [
      • Fricke K.
      • et al.
      Time course of the induction of homeostatic plasticity generated by repeated transcranial direct current stimulation of the human motor cortex.
      ,
      • Doeltgen S.H.
      • Ridding M.C.
      Low-intensity, short-interval theta burst stimulation modulates excitatory but not inhibitory motor networks.
      ]. The few data presently available suggest that homeostatic plasticity is less consistently expressed. Alternatively, homeostatic plasticity in intracortical circuits upstream to the corticospinal motor neuron may simply be more difficult to capture with MEP measurements. Subtle homeostatic changes may have an effect size that remains within the noise level of normal fluctuations in MEP amplitude. More robust homeostatic effects in intracortical circuits are likely to be paralleled by concurrent homeostatic changes in the corticospinal neurons. In that case, the presence of homeostatic changes in MEP amplitude evoked by single-pulse TMS may mask homeostatic effects in upstream intracortical circuits as probed with double-pulse TMS.

      Intercortical homeostatic plasticity

      Homeostatic interactions can also occur in interregional networks. Several studies have shown that a homeostatic response can be elicited in M1 when the priming protocol is given over a secondary motor area to activate cortico-cortical projections to M1. Potter-Nerger and coworkers (2009) demonstrated homeostatic priming on PAS to left M1 after rTMS priming was applied to ipsilateral dorsal premotor cortex (dPMC). Thus, inhibitory 1Hz rTMS of dPMC prior to an inhibitory PAS protocol over M1 increased M1 excitability, whereas facilitatory 5Hz rTMS of dPMC prior to a facilitatory PAS protocol over M1 suppressed M1 excitability [
      • Potter-Nerger M.
      • et al.
      Inducing homeostatic-like plasticity in human motor cortex through converging corticocortical inputs.
      ]. Homeostatic modulation of M1 excitability was also demonstrated when a priming QPS session was given to the supplementary motor area [
      • Hamada M.
      • et al.
      Primary motor cortical metaplasticity induced by priming over the supplementary motor area.
      ] or when a priming 1Hz rTMS was given to the contralateral M1 [
      • Ragert P.
      • et al.
      Modulation of effects of intermittent theta burst stimulation applied over primary motor cortex (M1) by conditioning stimulation of the opposite M1.
      ]. Taken together, these findings indicate that homeostatic interactions can be elicited through different input channels in the human M1.
      Studies using other measures of cortical excitability, such as somatosensory evoked potentials (SSEP) or visual evoked potentials (VEP), have shown that homeostatic metaplasticity can also be expressed in other cortical areas. SSEP recordings provided evidence for homeostatic plasticity in primary somatosensory cortex [
      • Bliem B.
      • et al.
      Homeostatic metaplasticity in the human somatosensory cortex.
      ,
      • Gatica Tossi M.A.
      • et al.
      Behavioural and neurophysiological markers reveal differential sensitivity to homeostatic interactions between centrally and peripherally applied passive stimulation.
      ]. Both studies used an NTBS prime preceding a high-frequency tactile stimulation (HFS) protocol of the contralateral hand in order to demonstrate a homeostatic response in the somatosensory cortex. In primary visual cortex, VEP) revealed a homeostatic reaction to a combined TDCS-rTMS protocol [
      • Bocci T.
      • et al.
      Evidence for metaplasticity in the human visual cortex.
      ]. Identifying additional neurophysiological markers of brain plasticity such as recordings of TMS-evoked cortical potentials with combined TMS-EEG [
      • Rajji T.K.
      • et al.
      PAS-induced potentiation of cortical-evoked activity in the dorsolateral prefrontal cortex.
      ] might facilitate investigations into homeostatic effects expressed in other cortical areas.

      Homeostatic plasticity and motor learning

      Motor learning can induce plasticity under physiological conditions and many studies have shown that brain stimulation and motor learning can interact homeostatically. Early studies showed that a simple motor learning task could act as a ‘primer’ for subsequent PAS protocols. Ziemann and coworkers [
      • Ziemann U.
      • et al.
      Learning modifies subsequent induction of long-term potentiation-like and long-term depression-like plasticity in human motor cortex.
      ] showed that motor learning prevented the induction of subsequent LTP-like PAS effects while enhancing subsequent LTD-like effects. More recent work suggests that observation of a motor training task is sufficient to prevent subsequent induction of LTP-like PAS effects [
      • Lepage J.F.
      • et al.
      Occlusion of LTP-like plasticity in human primary motor cortex by action observation.
      ] and that the temporary occlusion of LTP-like plasticity after motor learning is likely to be a mechanism necessary for successful skill retention (Cantarero et al., 2013a; Cantarero et al., 2013b). Retention for a simple motor task after learning was proportional to the magnitude of LTP occlusion during a subsequent NTBS protocol and that the amount of occlusion was predictive of resilience against interference of subsequent learning [
      • Cantarero G.
      • Lloyd A.
      • Celnik P.
      Reversal of long-term potentiation-like plasticity processes after motor learning disrupts skill retention.
      ,
      • Cantarero G.
      • et al.
      Motor learning interference is proportional to occlusion of LTP-like plasticity.
      ]. Interestingly, the effect of motor learning as a ‘primer’ depends on the learning phase: the observed homeostatic effects on subsequent PAS protocols were only observed when ‘priming’ involved training a novel motor task, while ‘priming’ with a well-practiced task did not significantly modulate subsequent PAS [
      • Rosenkranz K.
      • Kacar A.
      • Rothwell J.C.
      Differential modulation of motor cortical plasticity and excitability in early and late phases of human motor learning.
      ].
      While these studies clearly demonstrate that learning may have a homeostatic impact on plasticity induced by subsequent NTBS, the evidence for a reverse interaction, a homeostatic effect of NTBS on plasticity induced by subsequent motor learning is less consistent. According to the BMC theory, one might expect an inhibitory NTBS protocol to facilitate a subsequent motor leaning task. Jung and Ziemann [
      • Jung P.
      • Ziemann U.
      Homeostatic and nonhomeostatic modulation of learning in human motor cortex.
      ] studied motor learning of rapid thumb abduction movements. The training session was primed with a PAS protocol which ended 0 min or 90 min before training began. When PAS was given directly before training, both the inhibitory and excitatory PAS protocol enhanced motor learning, indicating a non-homeostatic interaction. However, the same PAS protocols given 90 min before learning gave rise to a “classic” homeostatic interaction. In that condition, excitability-decreasing PAS still had a beneficial effect on motor learning, but excitability-increasing PAS impaired motor learning. These results once again stress the importance of timing between priming and test protocols and suggest that non-homeostatic mechanisms may play a role, especially when the interval between priming stimulation and motor training is short.
      Studying homeostatic plasticity in the context of motor learning is difficult, since synaptic strengthening is likely not the only factor influencing the learning rate. A more recent study found that priming with iTBS boosted performance in a subsequent ballistic motor learning task [
      • Teo J.T.
      • et al.
      Human theta burst stimulation enhances subsequent motor learning and increases performance variability.
      ]. In that study, the beneficial effect of priming iTBS was blocked by the administration of nicotine. Behavioral analysis and modeling suggested that the iTBS prime facilitated performance by increasing motor output variability. The hypothesis was that the motor system could then explore the task workspace more quickly to find the optimal way to perform the task. The authors hypothesized that nicotine blocked this effect, presumably by reducing the signal-to-noise ratio in cerebral cortex [
      • Teo J.T.
      • et al.
      Human theta burst stimulation enhances subsequent motor learning and increases performance variability.
      ]. This and other mechanisms may explain why other studies, which assessed the priming effects of brain stimulation on motor learning, failed to reveal homeostatic effects [
      • Kuo M.F.
      • et al.
      Limited impact of homeostatic plasticity on motor learning in humans.
      ].
      Many studies consistently show that NTBS protocols that are sub-threshold for inducing action potentials in the cortex, in particular TDCS, can enhance motor learning when the NTBS protocol is given concurrently with the learning task [
      • Nitsche M.A.
      • et al.
      Facilitation of implicit motor learning by weak transcranial direct current stimulation of the primary motor cortex in the human.
      ,
      • Antal A.
      • et al.
      Facilitation of visuo-motor learning by transcranial direct current stimulation of the motor and extrastriate visual areas in humans.
      ,
      • Reis J.
      • et al.
      Noninvasive cortical stimulation enhances motor skill acquisition over multiple days through an effect on consolidation.
      ,
      • Reis J.
      • Fritsch B.
      Modulation of motor performance and motor learning by transcranial direct current stimulation.
      ,
      • Schambra H.M.
      • et al.
      Probing for hemispheric specialization for motor skill learning: a transcranial direct current stimulation study.
      ,
      • Stagg C.J.
      • et al.
      Polarity and timing-dependent effects of transcranial direct current stimulation in explicit motor learning.
      ]. Although most NTBS protocols that were applied during motor training enhanced motor learning in a non-homeostatic fashion, homeostatic interaction might well occur. However, this should not be called “metaplasticity”, because priming and test intervention are not separated in time [
      • Abraham W.C.
      Metaplasticity: tuning synapses and networks for plasticity.
      ]. An optimal exploitation of homeostatic mechanisms to boost motor learning will require a better understanding of the mechanisms by which the various NTBS protocols modulate motor learning.

      Gating vs. homeostatic plasticity

      The interactions between motor training and concurrent NTBS often follow non-homeostatic rules (i.e., the priming intervention does not have a homeostatic effect on the test procedure). A complementary mechanism by which NTBS might increase the beneficial effects of motor learning is ‘gating’. Gating mechanisms may also increase the efficacy of NTBS of the M1 to produce LTP-like or LTD-like effects. Gating may be provoked by several mechanisms such as increasing net calcium influx into the targeted cortical neurons, shifting intrinsic excitability of the targeted neurons (e.g., sub-threshold depolarization during anodal TDCS), or transiently suppressing the efficacy of intracortical inhibitory circuits. It is important to point out that gating is a non-homeostatic mechanism, because it does not alter the threshold for expressing LTP or LTD [
      • Ziemann U.
      • Siebner H.R.
      Modifying motor learning through gating and homeostatic metaplasticity.
      ]. Yet gating may promote the induction of LTP-like effects in neural circuits targeted by NTBS or learning and indirectly facilitate a homeostatic response.
      It is also important to note that not all interactions between consecutively paired protocols depend on homeostatic effects and that several forms of non-homeostatic metaplasticity have been observed using brain stimulation: A very low frequency (0.1 Hz) rTMS prime given to M1 abolished the ability to induce LTP- and LTD-like effects in the primed M1 with subsequent PAS [
      • Delvendahl I.
      • et al.
      Occlusion of bidirectional plasticity by preceding low-frequency stimulation in the human motor cortex.
      ,
      • Siebner H.R.
      A primer on priming the human motor cortex.
      ]. The prime alone did not alter corticospinal excitability as measured by MEP amplitude, but increased short-interval and long-interval intracortical inhibition in the stimulated M1. Increased excitability of intracortical inhibitory circuits caused by the priming protocol might have prevented the PAS protocol from inducing LTP- or LTD-like changes in corticospinal excitability, potentially by reducing the calcium influx in the corticospinal neurons during PAS [
      • Delvendahl I.
      • et al.
      Occlusion of bidirectional plasticity by preceding low-frequency stimulation in the human motor cortex.
      ,
      • Siebner H.R.
      A primer on priming the human motor cortex.
      ]. A reduction of the calcium influx caused by increased activity of intracortical inhibitory circuits does not invoke homeostatic regulation because the threshold for LTP and LTD induction is not principally shifted. Such a mechanism rather represents an ‘anti-gating’ effect that reduces the efficacy of NTBS without shifting the threshold for expressing LTP and LTD [
      • Delvendahl I.
      • et al.
      Occlusion of bidirectional plasticity by preceding low-frequency stimulation in the human motor cortex.
      ,
      • Siebner H.R.
      A primer on priming the human motor cortex.
      ].
      Another non-homeostatic form of metaplasticity is de-potentiation (or de-depression). De-potentiation erases previously induced LTP (or LTD) and may be the key mechanism for retrograde inference with learning. There is ample evidence for de-potentiation and de-depression in the animal literature, which implicates this form of metaplasticity as a factor in learning reversal and forgetting [
      • Larson J.
      • Xiao P.
      • Lynch G.
      Reversal of LTP by theta frequency stimulation.
      ,
      • Kulla A.
      • Manahan-Vaughan D.
      Depotentiation in the dentate gyrus of freely moving rats is modulated by D1/D5 dopamine receptors.
      ,
      • Huang C.C.
      • Liang Y.C.
      • Hsu K.S.
      Characterization of the mechanism underlying the reversal of long term potentiation by low frequency stimulation at hippocampal CA1 synapses.
      ]. Metaplasticity patterns resembling de-potentiation and de-depression were observed in an experiment that combined iTBS and cTBS [
      • Huang Y.Z.
      • et al.
      Reversal of plasticity-like effects in the human motor cortex.
      ]: The normal LTP-like effect induced by facilitatory iTBS was abolished (de-potentiated), when a short train of inhibitory cTBS followed the iTBS protocol. Vice versa, the LTD-like effect normally induced by a cTBS protocol was abolished (de-depressed), if followed by a short train of facilitatory iTBS. When given alone, the short TBS trains did not change corticomotor excitability. This shows that the de-potentiating (or de-depressing) protocol itself does not need to have any discernable effect when applied alone. Only when given within a certain time window after an LTP- or LTD-inducing protocol are these effects visible. The early phases of LTP and LTD induction are more vulnerable to the effect of interfering stimuli than later phases, when synaptic changes in synaptic efficacy have been stabilized [
      • Huang Y.Z.
      • et al.
      Reversal of plasticity-like effects in the human motor cortex.
      ].
      These examples show that there are many non-homeostatic forms of cortical plasticity and metaplasticity that might shape the efficacy of NTBS to induce LTP- or LTD-like effects. Hence, researchers investigating metaplasticity need to be careful when labeling a modulation of NTBS-induced plasticity as “homeostatic”. An effect is only likely to be homeostatic, if the priming intervention alters the LTP-LTD induction curve in a way that the changes in LTD-LTP induction threshold favor the induction of plasticity opposite to the priming protocol (Figure 2, Figure 3). As mentioned earlier, the temporal relationship between the priming and test protocols is crucial for the induction of both homeostatic and non-homeostatic metaplasticity. Future studies need to explore the interplay between these non-homeostatic and homeostatic forms of cortical plasticity.

      Mechanisms regulating metaplasticity

      One of the key predictions of the original BCM theory is that the activity dependent threshold is calculated from a running time-average of post-synaptic action potential activity. More recent BCM models have, however, started to question the role of post-synaptic action potentials and focused on the time-averaged free calcium concentration as the biological signal controlling homeostatic metaplasticity [
      • Shouval H.Z.
      • Bear M.F.
      • Cooper L.N.
      A unified model of NMDA receptor-dependent bidirectional synaptic plasticity.
      ,
      • Yeung L.C.
      • et al.
      Synaptic homeostasis and input selectivity follow from a calcium-dependent plasticity model.
      ]. Recent in vitro experiments confirmed that homeostatic plasticity in the hippocampus did not depend on somatic action potentials, but was determined by calcium release from intra-cellular stores, triggered by muscarinic acetylcholine receptors [
      • Hulme S.R.
      • et al.
      Calcium-dependent but action potential-independent BCM-like metaplasticity in the hippocampus.
      ]. In addition to intra-cellular Ca2+stores, Ca2+ can also enter the cell via NMDA receptors or via L-type voltage-gated Ca2+ channels. Homeostatic modulation of high-frequency tetanic stimulation was also observed when pharmacologically reducing Ca2+ via those routes [
      • Mizuno T.
      • Kanazawa I.
      • Sakurai M.
      Differential induction of LTP and LTD is not determined solely by instantaneous calcium concentration: an essential involvement of a temporal factor.
      ,
      • Cummings J.A.
      • et al.
      Ca2+ signaling requirements for long-term depression in the hippocampus.
      ,
      • Hirsch J.C.
      • Crepel F.
      Blockade of NMDA receptors unmasks a long-term depression in synaptic efficacy in rat prefrontal neurons in vitro.
      ].
      A study combining an acute pharmacological intervention with cTBS showed that the magnitude of Ca2+ signaling is also highly relevant for the induction of LTP- and LTD-like phenomena in humans [
      • Wankerl K.
      • et al.
      L-type voltage-gated Ca2+ channels: a single molecular switch for long-term potentiation/long-term depression-like plasticity and activity-dependent metaplasticity in humans.
      ]. When the duration of cTBS was shortened from 40 s to 20 s, cTBS was shown to induce a facilitatory effect on corticomotor excitability [
      • Gentner R.
      • et al.
      Depression of human corticospinal excitability induced by magnetic theta-burst stimulation: evidence of rapid polarity-reversing metaplasticity.
      ]. These LTP-like effects of short cTBS on corticomotor excitability were reversed when healthy volunteers were treated with nimodipine, an L-type voltage-gated Ca2+ channel antagonist. Pharmacological blockade of the NMDA receptor by dextromethorphan did not cause a homeostatic effect, but dextromethorphan abolished both the LTD-like effect of cTBS produced by nimodipine and the normal LTP-like effect of cTBS alone in M1. This study also suggested that the homeostatic effects induced by voluntary activity might be mediated by L-type voltage-gated calcium channels. It is likely that the effects of other interventional NTBS protocols are also strongly influenced by Ca2+ dynamics, but might be sensitive to manipulation of Ca2+ influx via different routes. This remains a relevant topic for future research.
      At the cellular level, a complex machinery of transcriptional as well as pre- and post-synaptic molecular signaling mechanisms can induce and shape homeostatic mechanisms. These mechanisms include secreted molecules such as the brain-derived neurotrophic factor (BDNF) or the tumor necrosis factor (TNF), cell adhesion molecules (e.g., integrins, ephrins, cadherins), different kinases (CaMKs, CaMKII) and transcription factors such as Arg3.1 (for a detailed review on the molecular mechanisms of homeostatic plasticity the reader is referred to Ref. [
      • Pozo K.
      • Goda Y.
      Unraveling mechanisms of homeostatic synaptic plasticity.
      ]).

      Synaptic homeostasis and sleep

      While neurons can undergo specific plastic changes during learning and behavior, they also have many ways to keep overall synaptic weights and post-synaptic activity levels under control. It has been proposed that irrespective of the specific mechanism involved, achieving this control may require the alternation between wakefulness and sleep [
      • Tononi G.
      • Cirelli C.
      Sleep and the price of plasticity: from synaptic and cellular homeostasis to memory consolidation and integration.
      ]. Specifically, according to the “synaptic homeostasis hypothesis”, the fundamental function of sleep is the restoration of synaptic homeostasis, which is challenged by synaptic strengthening triggered by learning during wakefulness [
      • Tononi G.
      • Cirelli C.
      Sleep and the price of plasticity: from synaptic and cellular homeostasis to memory consolidation and integration.
      ]. In this framework, sleep is the price we pay for having a plastic brain that is able to learn and adapt to the ever-changing demands of the environment. Since neurons signal suspicious coincidences and salient events by increasing their firing, learning should happen primarily through synaptic potentiation. Moreover, synaptic potentiation should occur mainly during wakefulness in order to be adaptive, when the brain interacts with the external environment, not during sleep when it is disconnected. Hence, wakefulness is associated with synaptic potentiation and net synaptic weight increases over the wakening hours. Increased synaptic strength during waking has obvious benefits but also various costs at the cellular and systems level; for example, it implies higher energy consumption and demand for the synthesis and delivery of synaptic supplies; in addition, it reduces the selectivity of neuronal responses and saturates the ability to learn. For this reason, neurons must eventually re-normalize total synaptic strength in order to restore cellular functions as well as selectivity. Indeed, the other main tenet of the synaptic homeostasis hypothesis is that re-normalization of synaptic strength occurs primarily during sleep, when the brain is spontaneously active offline, not in wake when a neuron's inputs are biased by a particular situation.
      It is important to note that homeostatic plasticity, as described in previous sections, and synaptic sleep homeostasis are related but separate phenomena. Whereas the primary variable regulated by homeostatic plasticity is the level of neural activity [
      • Turrigiano G.
      Homeostatic synaptic plasticity: local and global mechanisms for stabilizing neuronal function.
      ], sleep homeostasis primarily acts on global synaptic strength. An intriguing hypothesis is that synaptic re-normalization during sleep may be brought about by slow waves and by the underlying alternation between burst firing and neuronal silence. While the relevance and the details of this mechanism remain unknown, experimental studies in animal models show that overall synaptic weights increase during wakefulness but decrease during sleep. For example, structural evidence demonstrates that the strength, the size and number of synapses in the brain of Drosophila flies increase after a period of wakefulness and decrease only when animals are allowed to sleep [
      • Gilestro G.F.
      • Tononi G.
      • Cirelli C.
      Widespread changes in synaptic markers as a function of sleep and wakefulness in Drosophila.
      ,
      • Bushey D.
      • Tononi G.
      • Cirelli C.
      Sleep and synaptic homeostasis: structural evidence in Drosophila.
      ]. From a molecular point of view, the levels of GluA1-containing AMPA receptors (a molecular marker of synaptic potentiation) were found to be 30–40% higher after wakefulness than after sleep in rats [
      • Vyazovskiy V.V.
      • et al.
      Molecular and electrophysiological evidence for net synaptic potentiation in wake and depression in sleep.
      ]. Electrophysiologically, the slope of the early (monosynaptic) response evoked by electrical stimulation delivered in the rat cerebral cortex, a classic marker of synaptic strength in vivo, increases with time spent awake and decreases with time spent asleep [
      • Vyazovskiy V.V.
      • et al.
      Molecular and electrophysiological evidence for net synaptic potentiation in wake and depression in sleep.
      ].
      In humans, a similar measurement can be performed by simultaneous TMS-EEG a technique that allows the immediate electrical response of populations of cortical neurons to be measured after direct perturbation of the cerebral cortex. This technique has high test-retest reproducibility, provided that stimulation parameters are controlled by means of TMS neuro-navigation [
      • Lioumis P.
      • et al.
      Reproducibility of TMS-evoked EEG responses.
      ], and has sufficient accuracy to detect and track plastic changes occurring in the cerebral cortex at the individual subject's level [
      • Casarotto S.
      • et al.
      EEG responses to TMS are sensitive to changes in the perturbation parameters and repeatable over time.
      ]. Indeed, a recent study [
      • Huber R.
      • et al.
      Human cortical excitability increases with time awake.
      ] employing TMS-EEG showed that the amplitude and the slope of the early (0–20 ms) EEG response to TMS increase significantly in single subjects with time spent awake – from morning to evening and after one night of sleep deprivation – and that they decrease after recovery sleep. A similar shift of the excitation/inhibition balance toward excitation was documented by two TMS-MEPs studies [
      • Civardi C.
      • et al.
      Transcranial magnetic stimulation can be used to test connections to primary motor areas from frontal and medial cortex in humans.
      ,
      • Kreuzer P.M.
      • et al.
      Can temporal repetitive transcranial magnetic stimulation be enhanced by targeting affective components of tinnitus with frontal rTMS? A randomized controlled pilot trial.
      ] that detected a significant decrease of short-term intracortical inhibition occurring, at the group level, after 24 h of sleep deprivation. While providing some information on the nature of cortical plastic changes, these NTBS studies confirm the idea that in humans, sleep may contribute to keep the overall weight of cortical synapses under control. A practical implication is that synaptic sleep homeostasis needs to be taken into account whenever interventional NTBS protocols are given over consecutive days or weeks. In these studies, the sleep quality might have substantial impact on the emergence of cumulative NTBS effects.

      Homeostatic plasticity in pathological states

      Synaptic homeostasis has been demonstrated to be a fundamental mechanism within brain circuits, operating in different species including humans [
      • Turrigiano G.G.
      • Nelson S.B.
      Homeostatic plasticity in the developing nervous system.
      ,
      • Turrigiano G.
      Homeostatic synaptic plasticity: local and global mechanisms for stabilizing neuronal function.
      ,
      • Pozo K.
      • Goda Y.
      Unraveling mechanisms of homeostatic synaptic plasticity.
      ,
      • Grunwald M.E.
      • et al.
      Clathrin-mediated endocytosis is required for compensatory regulation of GLR-1 glutamate receptors after activity blockade.
      ,
      • Marder E.
      • Goaillard J.M.
      Variability, compensation and homeostasis in neuron and network function.
      ,
      • Vitureira N.
      • Letellier M.
      • Goda Y.
      Homeostatic synaptic plasticity: from single synapses to neural circuits.
      ], but much less is known about the significance of dysfunctional homeostatic plasticity for the pathogenesis and pathophysiology of brain diseases. In this review, we focus on a series of experiments, which have used NTBS to probe homeostatic plasticity in focal dystonia and discuss the future potential of NTBS to study homeostatic plasticity in neuropsychiatric disorders.

      Focal dystonia

      Using TDCS as conditioning protocol and low-frequency (1 Hz) rTMS as test protocol, Quartarone et al. found that the ‘homeostatic’ response pattern of healthy controls was absent in the affected hand of writer's cramp patients [
      • Quartarone A.
      • Pisani A.
      Abnormal plasticity in dystonia: disruption of synaptic homeostasis.
      ,
      • Quartarone A.
      • et al.
      Homeostatic-like plasticity of the primary motor hand area is impaired in focal hand dystonia.
      ]. In dystonic patients, aTDCS to M1 increased MEP amplitude as in normal controls, but the subsequent 1Hz rTMS did not produce an LTD-like effect. Thus despite producing an LTP-like effect, aTDCS failed to trigger a homeostatic response that sensitized M1 to the LTD-inducing effect of 1Hz rTMS.
      A subsequent study addressed the question whether patients with focal hand dystonia would show an enhancement of motor learning induced plasticity after priming with an excitability-reducing NTBS protocol as previously shown in healthy individuals [
      • Jung P.
      • Ziemann U.
      Homeostatic and nonhomeostatic modulation of learning in human motor cortex.
      ]. While the healthy control group showed a homeostatic enhancement of learning-dependent plasticity following an excitability-reducing prime and a homeostatic suppression of learning-dependent plasticity following an excitability-increasing prime, the writer's cramp patients did not show any modulation of learning-dependent plasticity and the lack of homeostatic modulation was correlated with the clinical severity of the dystonia [
      • Kang J.S.
      • et al.
      Deficient homeostatic regulation of practice-dependent plasticity in writer's cramp.
      ]. These results suggest that focal hand dystonia is associated with a dysfunctional homeostatic regulation of plasticity, which might set the frame for aberrant sensorimotor plasticity. Indeed, several NTBS studies have shown that patients with focal hand dystonia show excessive sensorimotor plasticity with lack of somatotopic specificity [
      • Quartarone A.
      • et al.
      Enhanced long-term potentiation-like plasticity of the trigeminal blink reflex circuit in blepharospasm.
      ,
      • Weise D.
      • et al.
      Loss of topographic specificity of LTD-like plasticity is a trait marker in focal dystonia.
      ]. It should be noted though that focal dystonia is also characterized by deficient inhibition within intracortical circuits [
      • Siebner H.R.
      • et al.
      Low-frequency repetitive transcranial magnetic stimulation of the motor cortex in writer's cramp.
      ]. Hence, deficient intracortical inhibition might also produce an abnormal “gating” of the LTP-inducing effects of NTBS and hereby introduce a bias towards producing LTP-like rather than LTD-like effects in M1.

      Parkinson's disease

      There is ample evidence for altered LTP- and LTD-like plasticity in Parkinson's disease (PD) [
      • Koch G.
      Do studies on cortical plasticity provide a rationale for using non-invasive brain stimulation as a treatment for Parkinson's disease patients?.
      ,
      • Morgante F.
      • et al.
      Motor cortex plasticity in Parkinson's disease and levodopa-induced dyskinesias.
      ,
      • Bagnato S.
      • et al.
      Plasticity of the motor cortex in Parkinson's disease patients on and off therapy.
      ] and recent research suggests that abnormalities in plasticity may depend on disease state and l-DOPA administration [
      • Koch G.
      Do studies on cortical plasticity provide a rationale for using non-invasive brain stimulation as a treatment for Parkinson's disease patients?.
      ]. Despite the relatively large number of NTBS studies investigating synaptic plasticity in PD, homeostatic plasticity has not been systematically investigated. Huang et al. (2011) studied non-homeostatic metaplasticity in patients with and without levodopa-induced dyskinesia (LID). PD patients without LIDs had normal potentiation and de-potentiation, when they took their full dose of levodopa. Patients with levodopa-induced LIDs were studied while being on half their usual dose of levodopa to prevent emergence of overt dyskinesias during testing. LID patients showed normal potentiation but were unresponsive to the de-potentiation protocol [
      • Huang Y.Z.
      • et al.
      Abnormal bidirectional plasticity-like effects in Parkinson's disease.
      ]. Given this altered non-homeostatic metaplasticity in LID patients, it is possible that homeostatic plasticity might also be affected in PD.

      Psychiatric disorders

      Several lines of research suggest that both the NMDA- and GABA-ergic transmitter systems that participate in cortical plasticity are also involved in the pathophysiology of various psychiatric disorders such as schizophrenia (SCZ), major depressive disorder (MDD) and bipolar disorder [
      • Radhu N.
      • et al.
      Inhibition of the cortex using transcranial magnetic stimulation in psychiatric populations: current and future directions.
      ,
      • Daskalakis Z.J.
      • et al.
      Evidence for impaired cortical inhibition in schizophrenia using transcranial magnetic stimulation.
      ,
      • Benes F.M.
      • Berretta S.
      GABAergic interneurons: implications for understanding schizophrenia and bipolar disorder.
      ,
      • Fitzgerald P.B.
      • et al.
      Reduced plastic brain responses in schizophrenia: a transcranial magnetic stimulation study.
      ,
      • Greenberg B.D.
      • et al.
      Decreased neuronal inhibition in cerebral cortex in obsessive-compulsive disorder on transcranial magnetic stimulation.
      ]. Except for dysfunctional GABA and glutamatergic neurotransmission, key features of these disorders are abnormalities in the expression of several proteins which are important for synaptic plasticity and homeostatic plasticity (e.g., BDNF, dysindin, neurexin) [
      • Stefansson H.
      • et al.
      Association of neuregulin 1 with schizophrenia confirmed in a Scottish population.
      ,
      • Duman R.S.
      • Aghajanian G.K.
      Synaptic dysfunction in depression: potential therapeutic targets.
      ,
      • Wondolowski J.
      • Dickman D.
      Emerging links between homeostatic synaptic plasticity and neurological disease.
      ].
      Disrupted plasticity is an established part of the pathophysiology in schizophrenia (SCZ), and several neurophysiological experiments using a range of plasticity-inducing NTBS protocols have shown that LTP- and LTD-like effects are reduced in SCZ [
      • Fitzgerald P.B.
      • et al.
      Reduced plastic brain responses in schizophrenia: a transcranial magnetic stimulation study.
      ,
      • Hasan A.
      • et al.
      Impaired long-term depression in schizophrenia: a cathodal tDCS pilot study.
      ,
      • Hasan A.
      • et al.
      Dysfunctional long-term potentiation-like plasticity in schizophrenia revealed by transcranial direct current stimulation.
      ]. SCZ patients also demonstrate less use-dependent plasticity. By measuring the spontaneous direction of TMS-induced thumb movements before and after 30-min training in thumb abduction, Daskalakis and coworkers [
      • Daskalakis Z.J.
      • et al.
      Dysfunctional neural plasticity in patients with schizophrenia.
      ] found that M1 excitability was affected less in SCZ patients than healthy controls. Impaired cortical plasticity has also been reported in patients with major depressive disorder (MDD) who have reduced plasticity in response to TMS [
      • Player M.J.
      • et al.
      Neuroplasticity in depressed individuals compared with healthy controls.
      ] and visual evoked potentials [
      • Normann C.
      • et al.
      Long-term plasticity of visually evoked potentials in humans is altered in major depression.
      ].
      As in PD although there is ample evidence for altered LTP- and LTD-like plasticity in SCZ and MDD, direct examples of impaired homeostatic plasticity are rare. On a molecular level, evidence exists linking various psychiatric diseases such as SCZ, MDD and other disorders to dysfunctional homeostatic synaptic plasticity involving a wide array of genes and molecules required for homeostatic synaptic plasticity [
      • Duman R.S.
      • Aghajanian G.K.
      Synaptic dysfunction in depression: potential therapeutic targets.
      ,
      • Wondolowski J.
      • Dickman D.
      Emerging links between homeostatic synaptic plasticity and neurological disease.
      ]. However, even though these molecular findings have led to a conceptual framework that places homeostatic dysfunction at the heart of a wide array of neurologic and psychiatric diseases there is, to the authors knowledge, no direct investigation of homeostatic regulation in psychiatric patient populations. Considering the links between the pathophysiology of a variety of psychiatric disorders and synaptic processes necessary for homeostatic control, it will be a future challenge to understand how these mechanisms work together in the intact human brain. A systematic investigation of homeostatic plasticity in various psychiatric disorders will help to start understanding how homeostatic responses orchestrate systemic functions in the brain.
      Dysfunctional synaptic plasticity and homeostatic plasticity in various disorders could have an impact on the design of future clinical trials. At the moment, treatment trials for several psychiatric disorders involve the application of plasticity-inducing NTBS protocols to counteract hypo- or hyperactivity of different brain areas. If, indeed, plasticity in these disorders is fundamentally changed, we cannot assume that the plasticity-enhancing effect of brain stimulation techniques, observed in healthy subjects, can be directly translated to patient populations. Indeed Barr et al. showed that one session of 20 Hz rTMS had opposing effects in SCZ patients and healthy volunteers: rTMS inhibited gamma-oscillatory activity in patients, who had a greater activity at baseline, while the same rTMS protocol potentiated gamma-oscillatory activity in healthy controls with relatively lower oscillations at baseline, suggesting a homeostatic interaction [
      • Barr M.S.
      • et al.
      The effect of repetitive transcranial magnetic stimulation on gamma oscillatory activity in schizophrenia.
      ].

      Conclusions and perspectives

      Homeostatic metaplasticity plays a critical role in stabilizing neural activity around a set point and is defined by inducing a shift in the stimulus–response curve of the firing neuron and is controlled by the intra-cellular Ca2+ levels. The use of NTBS allows homeostatic effects to be investigated on a systems level and in interaction with physiological conditions. Since NTBS activates a massive number of neurons, inducing action potentials in a mixture of inhibitory and excitatory cells, NTBS-induced plasticity cannot be equated with in vitro studies on synaptic plasticity. Additionally, the traditional measure of NTBS-induced excitability, the MEP, has confined most investigations of homeostatic effects in the intact human brain to the primary motor cortex.
      In the future a combination of NTBS with other brain mapping techniques will allow investigation of homeostatic phenomena to expand to cortical areas outside M1. A careful investigation of the network effects and the combination of NTBS with neuroimaging, pharmacology and animal studies will help to reveal more insights into the neural mechanisms underlying homeostasis at a systems level.
      Systematic investigation of individual differences in NTBS response will, in the future, allow researchers to move towards the use of individually adjusted protocols that take relevant neurophysiological state markers such as the dominating oscillation frequency of a target brain network into consideration. These custom made protocols may decrease inter-individual variance and make NTBS an even more powerful tool. The study of homeostatic plasticity in patients with neurological and psychiatric diseases is still very limited and future research should tackle this issue since it might give some insight into contribution of dysfunctional regulation of cortical plasticity to these conditions.

      References

        • Abbott L.F.
        • Nelson S.B.
        Synaptic plasticity: taming the beast.
        Nat Neurosci. 2000; : 1178-1183
        • Turrigiano G.G.
        • Nelson S.B.
        Homeostatic plasticity in the developing nervous system.
        Nat Rev Neurosci. 2004; 5: 97-107
        • Abraham W.C.
        Metaplasticity: tuning synapses and networks for plasticity.
        Nat Rev Neurosci. 2008; 9: 387
        • Hulme S.R.
        • Jones O.D.
        • Abraham W.C.
        Emerging roles of metaplasticity in behaviour and disease.
        Trends Neurosci. 2013; 36: 353-362
        • Karabanov A.
        • Ziemann U.
        • Classen J.
        • Siebner H.
        Understanding homeostatic plasticity.
        in: Miniussi C. Paulus W. Rossini P. Transcranial brain stimulation. Frontiers in Neuroscience. CRC Press, 2012: 230-244
        • Classen J.
        Plasticity.
        Handb Clin Neurol. 2013; 116: 525-534
        • Ziemann U.
        • Siebner H.R.
        Modifying motor learning through gating and homeostatic metaplasticity.
        Brain Stimul. 2008; 1: 60-66
        • Ziemann U.
        • et al.
        Learning modifies subsequent induction of long-term potentiation-like and long-term depression-like plasticity in human motor cortex.
        J Neurosci. 2004; 24: 1666-1672
        • Groppa S.
        • et al.
        A practical guide to diagnostic transcranial magnetic stimulation: report of an IFCN committee.
        Clin Neurophysiol. 2012; 123: 858-882
        • Siebner H.R.
        • Rothwell J.
        Transcranial magnetic stimulation: new insights into representational cortical plasticity.
        Exp Brain Res. 2003; 148: 1-16
        • Pascual-Leone A.
        • et al.
        Responses to rapid-rate transcranial magnetic stimulation of the human motor cortex.
        Brain. 1994; 117: 847-858
        • Huang Y.Z.
        • et al.
        Theta burst stimulation of the human motor cortex.
        Neuron. 2005; 45: 201-206
        • Thickbroom G.W.
        • et al.
        Repetitive paired-pulse TMS at I-wave periodicity markedly increases corticospinal excitability: a new technique for modulating synaptic plasticity.
        Clin Neurophysiol. 2006; 117: 61-66
        • Stefan K.
        • et al.
        Induction of plasticity in the human motor cortex by paired associative stimulation.
        Brain. 2000; 123: 572-584
        • Hamada M.
        • et al.
        Quadro-pulse stimulation is more effective than paired-pulse stimulation for plasticity induction of the human motor cortex.
        Clin Neurophysiol. 2007; 118: 2672-2682
        • Nitsche M.A.
        • et al.
        Transcranial direct current stimulation: state of the art 2008.
        Brain Stimul. 2008; 1: 206-223
        • Feldman D.E.
        Synaptic mechanisms for plasticity in neocortex.
        Annu Rev Neurosci. 2009; 32: 33-55
        • Sjostrom P.J.
        • et al.
        Dendritic excitability and synaptic plasticity.
        Physiol Rev. 2008; 88: 769-840
        • Foeller E.
        • Feldman D.E.
        Synaptic basis for developmental plasticity in somatosensory cortex.
        Curr Opin Neurobiol. 2004; 14: 89-95
        • Hensch T.K.
        Critical period plasticity in local cortical circuits.
        Nat Rev Neurosci. 2005; 6: 877-888
        • Lisman J.
        • Lichtman J.W.
        • Sanes J.R.
        LTP: perils and progress.
        Nat Rev Neurosci. 2003; 4: 926-929
        • Malenka R.C.
        • Bear M.F.
        LTP and LTD: an embarrassment of riches.
        Neuron. 2004; 44: 5-21
        • Turrigiano G.G.
        • Nelson S.B.
        Hebb and homeostasis in neuronal plasticity.
        Curr Opin Neurobiol. 2000; 10: 358-364
        • Hebb D.
        The organization of behavior.
        Wiley & Sons, , New York1949
        • Abraham W.C.
        • Bear M.F.
        Metaplasticity: the plasticity of synaptic plasticity.
        Trends Neurosci. 1996; 19: 126-130
        • Alvarez V.A.
        • Sabatini B.L.
        Anatomical and physiological plasticity of dendritic spines.
        Annu Rev Neurosci. 2007; 30: 79-97
        • Shouval H.Z.
        • Bear M.F.
        • Cooper L.N.
        A unified model of NMDA receptor-dependent bidirectional synaptic plasticity.
        Proc Natl Acad Sci U S A. 2002; 99: 10831-10836
        • Turrigiano G.G.
        The self-tuning neuron: synaptic scaling of excitatory synapses.
        Cell. 2008; 135: 422-435
        • Tsumoto T.
        Long-term potentiation and long-term depression in the neocortex.
        Prog Neurobiol. 1992; 39: 209-228
        • Lisman J.
        A mechanism for the Hebb and the anti-Hebb processes underlying learning and memory.
        Proc Natl Acad Sci U S A. 1989; 86: 9574-9578
        • Artola A.
        • Singer W.
        Long-term depression of excitatory synaptic transmission and its relationship to long-term potentiation.
        Trends Neurosci. 1993; 16: 480-487
        • Yang S.N.
        • Tang Y.G.
        • Zucker R.S.
        Selective induction of LTP and LTD by postsynaptic [Ca2+]i elevation.
        J Neurophysiol. 1999; 81: 781-787
        • Artola A.
        • Brocher S.
        • Singer W.
        Different voltage-dependent thresholds for inducing long-term depression and long-term potentiation in slices of rat visual cortex.
        Nature. 1990; 347: 69-72
        • Bear M.F.
        Bidirectional synaptic plasticity: from theory to reality.
        Philos Trans R Soc Lond B Biol Sci. 2003; 358: 649-655
        • Turrigiano G.
        Too many cooks? Intrinsic and synaptic homeostatic mechanisms in cortical circuit refinement.
        Annu Rev Neurosci. 2011; 34: 89-103
        • Turrigiano G.
        Homeostatic synaptic plasticity: local and global mechanisms for stabilizing neuronal function.
        Cold Spring Harb Perspect Biol. 2012; 4: a005736
        • Nelson S.B.
        • Turrigiano G.G.
        Strength through diversity.
        Neuron. 2008; 60: 477-482
        • Cooper L.N.
        • Bear M.F.
        The BCM theory of synapse modification at 30: interaction of theory with experiment.
        Nat Rev Neurosci. 2012; 13: 798-810
        • Bienenstock E.L.
        • Cooper L.N.
        • Munro P.W.
        Theory for the development of neuron selectivity: orientation specificity and binocular interaction in visual cortex.
        J Neurosci. 1982; 2: 32-48
        • Kirkwood A.
        • Rioult M.C.
        • Bear M.F.
        Experience-dependent modification of synaptic plasticity in visual cortex.
        Nature. 1996; 381: 526-528
        • Wang H.
        • Wagner J.J.
        Priming-induced shift in synaptic plasticity in the rat hippocampus.
        J Neurophysiol. 1999; 82: 2024-2028
        • Hamada M.
        • et al.
        Primary motor cortical metaplasticity induced by priming over the supplementary motor area.
        J Physiol. 2009; 587: 4845-4862
        • Hamada M.
        • Ugawa Y.
        Quadripulse stimulation–a new patterned rTMS.
        Restor Neurol Neurosci. 2010; 28: 419-424
        • Hess G.
        • Aizenman C.D.
        • Donoghue J.P.
        Conditions for the induction of long-term potentiation in layer II/III horizontal connections of the rat motor cortex.
        J Neurophysiol. 1996; 75: 1765-1778
        • Castro-Alamancos M.A.
        • Donoghue J.P.
        • Connors B.W.
        Different forms of synaptic plasticity in somatosensory and motor areas of the neocortex.
        J Neurosci. 1995; 15: 5324-5333
        • Rioult-Pedotti M.S.
        • Friedman D.
        • Donoghue J.P.
        Learning-induced LTP in neocortex.
        Science. 2000; 290: 533-536
        • Massey P.V.
        • Bashir Z.I.
        Long-term depression: multiple forms and implications for brain function.
        Trends Neurosci. 2007; 30: 176-184
        • Cooke S.F.
        • Bliss T.V.
        Plasticity in the human central nervous system.
        Brain. 2006; 129: 1659-1673
        • Sharma N.
        • Classen J.
        • Cohen L.G.
        Neural plasticity and its contribution to functional recovery.
        Handb Clin Neurol. 2013; 110: 3-12
        • Takano B.
        • et al.
        Short-term modulation of regional excitability and blood flow in human motor cortex following rapid-rate transcranial magnetic stimulation.
        Neuroimage. 2004; 23: 849-859
        • Quartarone A.
        • Siebner H.R.
        • Rothwell J.C.
        Task-specific hand dystonia: can too much plasticity be bad for you?.
        Trends Neurosci. 2006; 29: 192-199
        • Hallett M.
        Transcranial magnetic stimulation: a primer.
        Neuron. 2007; 55: 187-199
        • Nyffeler T.
        • et al.
        Extending lifetime of plastic changes in the human brain.
        Eur J Neurosci. 2006; 24: 2961-2966
        • Hamada M.
        • et al.
        Bidirectional long-term motor cortical plasticity and metaplasticity induced by quadripulse transcranial magnetic stimulation.
        J Physiol. 2008; 586: 3927-3947
        • Classen J.
        • et al.
        Paired associative stimulation.
        Suppl Clin Neurophysiol. 2004; 57: 563-569
        • Rizzo V.
        • et al.
        Paired associative stimulation of left and right human motor cortex shapes interhemispheric motor inhibition based on a Hebbian mechanism.
        Cereb Cortex. 2009; 19: 907-915
        • Chao C.C.
        • et al.
        Induction of motor associative plasticity in the posterior parietal cortex-primary motor network.
        Cereb Cortex. 2013;
        • Arai N.
        • et al.
        State-dependent and timing-dependent bidirectional associative plasticity in the human SMA-M1 network.
        J Neurosci. 2011; 31: 15376-15383
        • Buch E.R.
        • et al.
        Noninvasive associative plasticity induction in a corticocortical pathway of the human brain.
        J Neurosci. 2011; 31: 17669-17679
        • Funke K.
        • Benali A.
        Modulation of cortical inhibition by rTMS – findings obtained from animal models.
        J Physiol. 2011; 589: 4423-4435
        • Pell G.S.
        • Roth Y.
        • Zangen A.
        Modulation of cortical excitability induced by repetitive transcranial magnetic stimulation: influence of timing and geometrical parameters and underlying mechanisms.
        Prog Neurobiol. 2011; 93: 59-98
        • Carson R.G.
        • Kennedy N.C.
        Modulation of human corticospinal excitability by paired associative stimulation.
        Front Hum Neurosci. 2013; 7: 823
        • Ziemann U.
        • et al.
        Consensus: motor cortex plasticity protocols.
        Brain Stimul. 2008; 1: 164-182
        • Muller-Dahlhaus F.
        • Ziemann U.
        Metaplasticity in human cortex.
        Neuroscientist. 2014;
        • Siebner H.R.
        • et al.
        Preconditioning of low-frequency repetitive transcranial magnetic stimulation with transcranial direct current stimulation: evidence for homeostatic plasticity in the human motor cortex.
        J Neurosci. 2004; 24: 3379-3385
        • Iyer M.B.
        • Schleper N.
        • Wassermann E.M.
        Priming stimulation enhances the depressant effect of low-frequency repetitive transcranial magnetic stimulation.
        J Neurosci. 2003; 23: 10867-10872
        • Lang N.
        • et al.
        Preconditioning with transcranial direct current stimulation sensitizes the motor cortex to rapid-rate transcranial magnetic stimulation and controls the direction of after-effects.
        Biol Psychiatry. 2004; 56: 634-639
        • Muller J.F.
        • et al.
        Homeostatic plasticity in human motor cortex demonstrated by two consecutive sessions of paired associative stimulation.
        Eur J Neurosci. 2007; 25: 3461-3468
        • Nitsche M.A.
        • et al.
        Timing-dependent modulation of associative plasticity by general network excitability in the human motor cortex.
        J Neurosci. 2007; 27: 3807-3812
        • Todd G.
        • Flavel S.C.
        • Ridding M.C.
        Priming theta-burst repetitive transcranial magnetic stimulation with low- and high-frequency stimulation.
        Exp Brain Res. 2009; 195: 307-315
        • Gentner R.
        • et al.
        Depression of human corticospinal excitability induced by magnetic theta-burst stimulation: evidence of rapid polarity-reversing metaplasticity.
        Cereb Cortex. 2008; 18: 2046-2053
        • Gamboa O.L.
        • et al.
        Simply longer is not better: reversal of theta burst after-effect with prolonged stimulation.
        Exp Brain Res. 2010; 204: 181-187
        • Rothkegel H.
        • Sommer M.
        • Paulus W.
        Breaks during 5Hz rTMS are essential for facilitatory after effects.
        Clin Neurophysiol. 2010; 121: 426-430
        • Fricke K.
        • et al.
        Time course of the induction of homeostatic plasticity generated by repeated transcranial direct current stimulation of the human motor cortex.
        J Neurophysiol. 2011; 105: 1141-1149
        • Karabanov A.
        • Siebner H.R.
        Unravelling homeostatic interactions in inhibitory and excitatory networks in human motor cortex.
        J Physiol. 2012; 590: 5557-5558
        • Di Lazzaro V.
        • Ziemann U.
        • Lemon R.N.
        State of the art: physiology of transcranial motor cortex stimulation.
        Brain Stimul. 2008; 1: 345-362
        • Reis J.
        • et al.
        Contribution of transcranial magnetic stimulation to the understanding of cortical mechanisms involved in motor control.
        J Physiol. 2008; 586: 325-351
        • Classen J.
        • et al.
        Integrative visuomotor behavior is associated with interregionally coherent oscillations in the human brain.
        J Neurophysiol. 1998; 79: 1567-1573
        • Rosenkranz K.
        • Kacar A.
        • Rothwell J.C.
        Differential modulation of motor cortical plasticity and excitability in early and late phases of human motor learning.
        J Neurosci. 2007; 27: 12058-12066
        • Doeltgen S.H.
        • Ridding M.C.
        Low-intensity, short-interval theta burst stimulation modulates excitatory but not inhibitory motor networks.
        Clin Neurophysiol. 2011; 122: 1411-1416
        • Kujirai T.
        • et al.
        Corticocortical inhibition in human motor cortex.
        J Physiol. 1993; 471: 501-519
        • Murakami T.
        • et al.
        Homeostatic metaplasticity of corticospinal excitatory and intracortical inhibitory neural circuits in human motor cortex.
        J Physiol. 2012; 590: 5765-5781
        • Potter-Nerger M.
        • et al.
        Inducing homeostatic-like plasticity in human motor cortex through converging corticocortical inputs.
        J Neurophysiol. 2009; 102: 3180-3190
        • Ragert P.
        • et al.
        Modulation of effects of intermittent theta burst stimulation applied over primary motor cortex (M1) by conditioning stimulation of the opposite M1.
        J Neurophysiol. 2009; 102: 766-773
        • Bliem B.
        • et al.
        Homeostatic metaplasticity in the human somatosensory cortex.
        J Cogn Neurosci. 2008; 20: 1517-1528
        • Gatica Tossi M.A.
        • et al.
        Behavioural and neurophysiological markers reveal differential sensitivity to homeostatic interactions between centrally and peripherally applied passive stimulation.
        Eur J Neurosci. 2013; 38: 2893-2901
        • Bocci T.
        • et al.
        Evidence for metaplasticity in the human visual cortex.
        J Neural Transm. 2014; 121: 221-231
        • Rajji T.K.
        • et al.
        PAS-induced potentiation of cortical-evoked activity in the dorsolateral prefrontal cortex.
        Neuropsychopharmacology. 2013; 38: 2545-2552
        • Lepage J.F.
        • et al.
        Occlusion of LTP-like plasticity in human primary motor cortex by action observation.
        PLoS One. 2012; 7: e38754
        • Cantarero G.
        • Lloyd A.
        • Celnik P.
        Reversal of long-term potentiation-like plasticity processes after motor learning disrupts skill retention.
        J Neurosci. 2013; 33: 12862-12869
        • Cantarero G.
        • et al.
        Motor learning interference is proportional to occlusion of LTP-like plasticity.
        J Neurosci. 2013; 33: 4634-4641
        • Jung P.
        • Ziemann U.
        Homeostatic and nonhomeostatic modulation of learning in human motor cortex.
        J Neurosci. 2009; 29: 5597-5604
        • Teo J.T.
        • et al.
        Human theta burst stimulation enhances subsequent motor learning and increases performance variability.
        Cereb Cortex. 2011; 21: 1627-1638
        • Kuo M.F.
        • et al.
        Limited impact of homeostatic plasticity on motor learning in humans.
        Neuropsychologia. 2008; 46: 2122-2128
        • Nitsche M.A.
        • et al.
        Facilitation of implicit motor learning by weak transcranial direct current stimulation of the primary motor cortex in the human.
        J Cogn Neurosci. 2003; 15: 619-626
        • Antal A.
        • et al.
        Facilitation of visuo-motor learning by transcranial direct current stimulation of the motor and extrastriate visual areas in humans.
        Eur J Neurosci. 2004; 19: 2888-2892
        • Reis J.
        • et al.
        Noninvasive cortical stimulation enhances motor skill acquisition over multiple days through an effect on consolidation.
        Proc Natl Acad Sci U S A. 2009; 106: 1590-1595
        • Reis J.
        • Fritsch B.
        Modulation of motor performance and motor learning by transcranial direct current stimulation.
        Curr Opin Neurol. 2011; 24: 590-596
        • Schambra H.M.
        • et al.
        Probing for hemispheric specialization for motor skill learning: a transcranial direct current stimulation study.
        J Neurophysiol. 2011; 106: 652-661
        • Stagg C.J.
        • et al.
        Polarity and timing-dependent effects of transcranial direct current stimulation in explicit motor learning.
        Neuropsychologia. 2011; 49: 800-804
        • Delvendahl I.
        • et al.
        Occlusion of bidirectional plasticity by preceding low-frequency stimulation in the human motor cortex.
        Clin Neurophysiol. 2010; 121: 594-602
        • Siebner H.R.
        A primer on priming the human motor cortex.
        Clin Neurophysiol. 2010; 121: 461-463
        • Larson J.
        • Xiao P.
        • Lynch G.
        Reversal of LTP by theta frequency stimulation.
        Brain Res. 1993; 600: 97-102
        • Kulla A.
        • Manahan-Vaughan D.
        Depotentiation in the dentate gyrus of freely moving rats is modulated by D1/D5 dopamine receptors.
        Cereb Cortex. 2000; 10: 614-620
        • Huang C.C.
        • Liang Y.C.
        • Hsu K.S.
        Characterization of the mechanism underlying the reversal of long term potentiation by low frequency stimulation at hippocampal CA1 synapses.
        J Biol Chem. 2001; 276: 48108-48117
        • Huang Y.Z.
        • et al.
        Reversal of plasticity-like effects in the human motor cortex.
        J Physiol. 2010; 588: 3683-3693
        • Yeung L.C.
        • et al.
        Synaptic homeostasis and input selectivity follow from a calcium-dependent plasticity model.
        Proc Natl Acad Sci U S A. 2004; 101: 14943-14948
        • Hulme S.R.
        • et al.
        Calcium-dependent but action potential-independent BCM-like metaplasticity in the hippocampus.
        J Neurosci. 2012; 32: 6785-6794
        • Mizuno T.
        • Kanazawa I.
        • Sakurai M.
        Differential induction of LTP and LTD is not determined solely by instantaneous calcium concentration: an essential involvement of a temporal factor.
        Eur J Neurosci. 2001; 14: 701-708
        • Cummings J.A.
        • et al.
        Ca2+ signaling requirements for long-term depression in the hippocampus.
        Neuron. 1996; 16: 825-833
        • Hirsch J.C.
        • Crepel F.
        Blockade of NMDA receptors unmasks a long-term depression in synaptic efficacy in rat prefrontal neurons in vitro.
        Exp Brain Res. 1991; 85: 621-624
        • Wankerl K.
        • et al.
        L-type voltage-gated Ca2+ channels: a single molecular switch for long-term potentiation/long-term depression-like plasticity and activity-dependent metaplasticity in humans.
        J Neurosci. 2010; 30: 6197-6204
        • Pozo K.
        • Goda Y.
        Unraveling mechanisms of homeostatic synaptic plasticity.
        Neuron. 2010; 66: 337-351
        • Tononi G.
        • Cirelli C.
        Sleep and the price of plasticity: from synaptic and cellular homeostasis to memory consolidation and integration.
        Neuron. 2014; 81: 12-34
        • Gilestro G.F.
        • Tononi G.
        • Cirelli C.
        Widespread changes in synaptic markers as a function of sleep and wakefulness in Drosophila.
        Science. 2009; 324: 109-112
        • Bushey D.
        • Tononi G.
        • Cirelli C.
        Sleep and synaptic homeostasis: structural evidence in Drosophila.
        Science. 2011; 332: 1576-1581
        • Vyazovskiy V.V.
        • et al.
        Molecular and electrophysiological evidence for net synaptic potentiation in wake and depression in sleep.
        Nat Neurosci. 2008; 11: 200-208
        • Lioumis P.
        • et al.
        Reproducibility of TMS-evoked EEG responses.
        Hum Brain Mapp. 2009; 30: 1387-1396
        • Casarotto S.
        • et al.
        EEG responses to TMS are sensitive to changes in the perturbation parameters and repeatable over time.
        PLoS One. 2010; 5: e10281
        • Huber R.
        • et al.
        Human cortical excitability increases with time awake.
        Cereb Cortex. 2013; 23: 332-338
        • Civardi C.
        • et al.
        Transcranial magnetic stimulation can be used to test connections to primary motor areas from frontal and medial cortex in humans.
        Neuroimage. 2001; 14: 1444-1453
        • Kreuzer P.M.
        • et al.
        Can temporal repetitive transcranial magnetic stimulation be enhanced by targeting affective components of tinnitus with frontal rTMS? A randomized controlled pilot trial.
        Front Syst Neurosci. 2011; 5: 88
        • Grunwald M.E.
        • et al.
        Clathrin-mediated endocytosis is required for compensatory regulation of GLR-1 glutamate receptors after activity blockade.
        Proc Natl Acad Sci U S A. 2004; 101: 3190-3195
        • Marder E.
        • Goaillard J.M.
        Variability, compensation and homeostasis in neuron and network function.
        Nat Rev Neurosci. 2006; 7: 563-574
        • Vitureira N.
        • Letellier M.
        • Goda Y.
        Homeostatic synaptic plasticity: from single synapses to neural circuits.
        Curr Opin Neurobiol. 2012; 22: 516-521
        • Quartarone A.
        • Pisani A.
        Abnormal plasticity in dystonia: disruption of synaptic homeostasis.
        Neurobiol Dis. 2011; 42: 162-170
        • Quartarone A.
        • et al.
        Homeostatic-like plasticity of the primary motor hand area is impaired in focal hand dystonia.
        Brain. 2005; 128: 1943-1950
        • Kang J.S.
        • et al.
        Deficient homeostatic regulation of practice-dependent plasticity in writer's cramp.
        Cereb Cortex. 2011; 21: 1203-1212
        • Quartarone A.
        • et al.
        Enhanced long-term potentiation-like plasticity of the trigeminal blink reflex circuit in blepharospasm.
        J Neurosci. 2006; 26: 716-721
        • Weise D.
        • et al.
        Loss of topographic specificity of LTD-like plasticity is a trait marker in focal dystonia.
        Neurobiol Dis. 2011; 42: 171-176
        • Siebner H.R.
        • et al.
        Low-frequency repetitive transcranial magnetic stimulation of the motor cortex in writer's cramp.
        Neurology. 1999; 52: 529-537
        • Koch G.
        Do studies on cortical plasticity provide a rationale for using non-invasive brain stimulation as a treatment for Parkinson's disease patients?.
        Front Neurol. 2013; 4: 180
        • Morgante F.
        • et al.
        Motor cortex plasticity in Parkinson's disease and levodopa-induced dyskinesias.
        Brain. 2006; 129: 1059-1069
        • Bagnato S.
        • et al.
        Plasticity of the motor cortex in Parkinson's disease patients on and off therapy.
        Mov Disord. 2006; 21: 639-645
        • Huang Y.Z.
        • et al.
        Abnormal bidirectional plasticity-like effects in Parkinson's disease.
        Brain. 2011; 134: 2312-2320
        • Radhu N.
        • et al.
        Inhibition of the cortex using transcranial magnetic stimulation in psychiatric populations: current and future directions.
        J Psychiatry Neurosci. 2012; 37: 369-378
        • Daskalakis Z.J.
        • et al.
        Evidence for impaired cortical inhibition in schizophrenia using transcranial magnetic stimulation.
        Arch Gen Psychiatry. 2002; 59: 347-354
        • Benes F.M.
        • Berretta S.
        GABAergic interneurons: implications for understanding schizophrenia and bipolar disorder.
        Neuropsychopharmacology. 2001; 25: 1-27
        • Fitzgerald P.B.
        • et al.
        Reduced plastic brain responses in schizophrenia: a transcranial magnetic stimulation study.
        Schizophr Res. 2004; 71: 17-26
        • Greenberg B.D.
        • et al.
        Decreased neuronal inhibition in cerebral cortex in obsessive-compulsive disorder on transcranial magnetic stimulation.
        Lancet. 1998; 352: 881-882
        • Stefansson H.
        • et al.
        Association of neuregulin 1 with schizophrenia confirmed in a Scottish population.
        Am J Hum Genet. 2003; 72: 83-87
        • Duman R.S.
        • Aghajanian G.K.
        Synaptic dysfunction in depression: potential therapeutic targets.
        Science. 2012; 338: 68-72
        • Wondolowski J.
        • Dickman D.
        Emerging links between homeostatic synaptic plasticity and neurological disease.
        Front Cell Neurosci. 2013; 7: 223
        • Hasan A.
        • et al.
        Impaired long-term depression in schizophrenia: a cathodal tDCS pilot study.
        Brain Stimul. 2012; 5: 475-483
        • Hasan A.
        • et al.
        Dysfunctional long-term potentiation-like plasticity in schizophrenia revealed by transcranial direct current stimulation.
        Behav Brain Res. 2011; 224: 15-22
        • Daskalakis Z.J.
        • et al.
        Dysfunctional neural plasticity in patients with schizophrenia.
        Arch Gen Psychiatry. 2008; 65: 378-385
        • Player M.J.
        • et al.
        Neuroplasticity in depressed individuals compared with healthy controls.
        Neuropsychopharmacology. 2013; 38: 2101-2108
        • Normann C.
        • et al.
        Long-term plasticity of visually evoked potentials in humans is altered in major depression.
        Biol Psychiatry. 2007; 62: 373-380
        • Barr M.S.
        • et al.
        The effect of repetitive transcranial magnetic stimulation on gamma oscillatory activity in schizophrenia.
        PLoS One. 2011; 6: e22627