Motor Rehabilitation Strategies Research Articles

Limb-girdle muscular dystrophies: A scoping review and overview of currently available rehabilitation strategies.

Limb-girdle muscular dystrophies (LGMDs) constitute a diverse group of inherited disorders primarily affecting skeletal muscle. Despite the absence of cures, rehabilitative treatments offer potential for preventing and mitigating loss of muscle strength. However, the role of exercise training in LGMD patients remains contentious. This review aims to provide an overview of the currently available motor rehabilitation strategies for the most common subtypes of LGMD. To identify relevant articles, we performed a systematic search in PubMed, Embase, Cochrane Library, and Web of Science, focusing on muscular and respiratory interventions. The search resulted in 560 potentially relevant articles, of which 16 were included in the review. Eight studies concentrated on neuromuscular functional rehabilitation therapy programs, seven combined both neuromuscular rehabilitation and interventions to maintain or enhance respiratory functionality and one focused on respiratory intervention only. Altogether, the papers examined offered a comprehensive view on the rehabilitative strategies available and provided an indication of the most valuable practices to deal with patients' health and needs. Upon analysis, we conclude that, when tailored to individual needs, muscle training can enhance strength and functional abilities, positively impacting psychological well-being. However, generic protocols may lead to limited benefits, fatigue, pain, and compliance issues. Moreover, early management of respiratory symptoms and personalized respiratory physiotherapy can enhance patients' well-being and their capability to participate in muscle training exercises. Future studies should not only refine rehabilitation approaches but also assess their impact on patients' quality of life, including psychological factors like depression and self-esteem.

Muscle synergies and muscle networks in multiple frequency components in post-stroke patients

As a neural control strategy employed by the central nervous system to control movements, the extraction of muscle synergies from a broad range of electromyographic signals has been the focus. Nevertheless, recent coherence analysis demonstrates distinct roles played in low-frequency components in motor control. This suggests that muscle synergies extracted from the low-frequency components can capture movement characteristics as done in the full-band. To investigate this issue, muscle synergies were extracted from three distinct frequency components (20–450 Hz, 20–30 Hz, 30–450 Hz) during spatial reaching movements in a group of healthy and stroke subjects. Synergy similarities were computed both within frequencies and between groups, and complex network analysis was conducted based on the group-averaged synergies. Results showed that the number and structure of muscle synergies, as well as network metrics, identified from the full-band (20–450 Hz) and low-frequency (20–30 Hz) exhibited high similarity between groups. These patterns diverged from those observed in high-frequency (30–450 Hz). The stroke did not induce significant alterations in muscle synergies. However, higher network metrics were identified in the full-band for one synergy. This study demonstrated the capacity of low-frequency components to perform muscle synergy analysis. These findings can help better understand the neural drive and motor control, potentially advancing the assessment of motor function and rehabilitation strategies.

Brain-computer interface in critical care and rehabilitation.

This comprehensive review explores the broad landscape of brain-computer interface (BCI) technology and its potential use in intensive care units (ICUs), particularly for patients with motor impairments such as quadriplegia or severe brain injury. By employing brain signals from various sensing techniques, BCIs offer enhanced communication and motor rehabilitation strategies for patients. This review underscores the concept and efficacy of noninvasive, electroencephalogram-based BCIs in facilitating both communicative interactions and motor function recovery. Additionally, it highlights the current research gap in intuitive "stop" mechanisms within motor rehabilitation protocols, emphasizing the need for advancements that prioritize patient safety and individualized responsiveness. Furthermore, it advocates for more focused research that considers the unique requirements of ICU environments to address the challenges arising from patient variability, fatigue, and limited applicability of current BCI systems outside of experimental settings.

Use of Botulinum Toxin for Limb Immobilization for Rehabilitation in Rats with Experimental Stroke.

Motor rehabilitation strategies after unilateral stroke suggest that the immobilization of the healthy, unimpaired limb can promote the functional recovery of a paretic limb. In rodents, this has been modeled using casts, harnesses, and other means of restricting the use of the non-paretic forelimb in models of experimental stroke. Here, we evaluated an alternative approach, using botulinum toxin injections to limit the function of the non-paretic forelimb. Adult male rats were subjected to permanent ligation of the left distal middle cerebral artery, resulting in right forelimb paresis. The rats were then subjected to: (1) no treatment; (2) botulinum toxin injections 1 day post stroke; or (3) cast placement 5 days post stroke. Casts were removed after 5 weeks, while the botulinum toxin injection effectively immobilized subjects for approximately the same duration. Rats with bilateral forelimb impairment due to the stroke plus casting or botulinum injections were still able to feed and groom normally. Both immobilization groups showed modest recovery following the stroke compared to those that did not receive immobilization, but the casting approach led to unacceptable levels of animal stress. The botulinum toxin approach to limb immobilization had both advantages and disadvantages over traditional physical limb immobilization. The major advantage was that it was far less stress-inducing to the subject animals and appeared to be well tolerated. A disadvantage was that the paresis took roughly 10 weeks to fully resolve, and any degree of residual paresis could confound the interpretation of the behavioral assessments.

Rehabilitation nach Schlaganfall

Neurorehabilitation to alleviate permanent disabilities after stroke is in Germany organised within the so called neurological phase model. This article provides an overview on its organisation and content as well as the restrictions imposed by social law. As an example for therapies, evidence-based motor rehabilitation strategies are presented and linked to their neurophysiological principles. Additionally, the current recommendations for the assessment of fitness to drive are illustrated.

In vivo electrophysiological mechanisms underlying cervical epidural stimulation in adult rats.

To electrophysiologically determine the predominant neural structures activated with cervical epidural stimulation (ES), well-established electrophysiological protocols (single-pulse, paired-pulse and multiple frequency stimulation) were delivered at rest, during motor activity and under anaesthesia in adult rats. Cervical ES resulted in spinal evoked motor responses with three different waveforms - early response (ER), middle response (MR) and late response (LR). ERs remained unmodulated by repeated stimulation protocols. In contrast, MRs and LRs were modulated by repeated stimulation protocols and volitional motor activity. ERs are consequential to the direct activation of motor efferents; MRs are secondary to type-I sensory afferent activation and LRs result from the engagement of wider spinal interneuronal circuitry with potential influence from supraspinal pathways. Evidence from this work is fundamental in enhancing our understanding of cervical ES, and critical in refining the design of neuromodulation-based rehabilitative strategies and in the construction of neuroprosthetics. Epidural stimulation (ES) of the lumbar spinal cord has demonstrated significant improvements in various physiological functions after a traumatic spinal cord injury in humans. Electrophysiological evidence from rodent, human and computational studies collectively suggest that the functional recovery following lumbar ES is mediated via direct activation of sensory afferent fibres. However, the mechanisms underlying cervical ES have not been comprehensively studied, which greatly limits our understanding of its effectiveness in restoring upper limb function. In this work, we determined the predominant neural structures that are activated with cervical ES using in vivo cervical spinal evoked motor responses (SEMRs). Standard electrophysiological protocols (single-pulse, paired-pulse and multiple frequency stimulation) were implemented in 11 awake and anaesthetized rats in four experimental stages. Three distinct types of cervical SEMRs were identified based on latency of their appearance: early response (ER), middle response (MR) and late response (LR). ERs remained unmodulated by repeated stimulation protocols. MRs and LRs were modulated by repeated stimulation protocols and volitional motor activity. Except for LRs being completely abolished under urethane, ketamine or urethane anaesthesia did not affect the appearance of cervical SEMRs. Our data, backed by literature, suggest that ERs are secondary to the direct activation of motor efferents, MRs are elicited by activation of type-I sensory afferents and LRs result from the engagement of interneuronal circuitry with potential influence from supraspinal pathways. The gathered information paves the way to designing motor rehabilitation strategies that can utilize cervical ES to recover upper limb function following neurological deficits.

Motor Imagery Training During Arm Immobilization Prevents Corticomotor Idling: An EEG Resting-State Analysis.

Limb disuse causes overt, measurable alterations in motor functions. Motor imagery (MI) practice has been used as a behavioral strategy to prevent motor impairments due to limb disuse or immobilization. Yet, how MI operates at the neural level in the context of short-term limb immobilization remains understudied. We hypothesized that MI treatment applied during 12h of arm immobilization prevents immobilization-related changes in resting-state electroencephalographic (rsEEG) power and functional connectivity. Fourteen participants first underwent rsEEG after 12h of normal motor activity (without immobilization). Then, rsEEG recording was performed after 12h of arm immobilization either with MI treatment or without, each conditionseparated by 1week, according to a randomized within-subjects design. MI treatment consisted in performing varied visual and kinaesthetic MI exercises (5 sessions of 15min every two hours). The results showed that in the delta, theta, alpha and beta frequency bands, interhemispheric difference in sensors power over the motor cortex (i.e. C3 vs. C4) was reduced after arm immobilization, while it did not change when MI treatment was delivered during the immobilization period. Moreover, functional connectivity across the sensors-network in the delta (1-4Hz) and alpha (8-12Hz) frequency bands decreased after immobilization while it was restored by MI treatment. To conclude, MI counteracts functional neural changes within and between motor regions in the context of limb immobilization. Practical applications for motor rehabilitation strategies, particularly in stroke patients, are also discussed.

A hypothetical explanatory sensorimotor model of bilateral limb interference

Goal-directed movements of a limb are optimized by sensorimotor integration, a process that merges both sensory and motor representations. In a previous study, we revealed that abnormal sensory representation can impair reach-to-grasp movements in patients with spinothalamocortical pathway lesions. This abnormal motor control was significantly recovered when referencing correct somatosensory information with the intact hand. Furthermore, motor control of the intact hand was impaired when referencing abnormal somatosensory information with the affected hand. Such bilateral limb interference suggests that there is only one common integrated sensory representation and only one common motor representation for both hands. The single sensory representation would be integrated from the somatosensory information received from both hands. Subsequently, the integrated motor representation would be derived from the integrated sensory representation, and would then be split and sent out via motor commands to both hands. Considering that bimanual coordinated movements are reportedly smoother than unimanual movements, information transfer between the integrated sensory and the integrated motor representation would be suitable for such efficient bimanual movements. Therefore, we propose a novel hypothetical model to better explain the observation of bilateral limb interference. The proposed model might contribute to the development of novel sensory and motor rehabilitation strategies by promoting the use of the unaffected hand.

The effect of virtual reality on left and right middle cerebral artery chronic stroke patients

There is a considerable body of evidence around the use of non-immersive virtual reality as a therapeutic modality in stroke rehabilitation. Studies report its use in isolation, and as an adjunct to traditional physical therapy approaches. Very little is known about what effect the location of lesion and the participants’ stage of recovery can have on the efficacy of VR interventions. We present a study using non-immersive VR in two groups consisting of right-middle or left-middle cerebral artery stroke survivors in the chronic stage. Seventeen chronic stroke patients participated in this study. Participants performed 30 sessions of therapy with a Virtual Reality system supervised by a physiotherapist. A series of cognitive (MMSE), ADL (FIM and Barthel), motor (MAS, FMA upper an lower limb and MRC), gait (6MWT, Tineti), spasticity (Asworth), balance (Berg and Tinetti EQ) and depression (GDS) scales were administered to each group of right middle cerebral artery or left middle cerebral artery stroke survivors. Participants with lesions in the left middle cerebral artery had significant improvements when compared with pre- and post-scores in the Barthel, FMA lower an upper, Berg and Tinetti. Participants with right cerebral artery lesions showed significant improvements on the Barthel Index and Fugl-Meyer (lower extremity). We suggest that lateralization may be influencing the different outcomes reported between the right and left cerebral artery stroke groups in this study. We conclude that future VR motor rehabilitation strategies should consider the location of the lesion when designing interventions and call for additional research on this topic.

Success of promotion strategies for a stroke rehabilitation protocol.

To prospectively evaluate the success of promotion strategies for a protocol of motor rehabilitation strategies for patients with stroke at Albert Einstein Hospital. In a clinical trial of neuromodulation and rehabilitation for patients with stroke, conventional methods of dissemination and publications about the research protocol in social networks or on the hospital's website were performed. Frequencies of types of advertisements that reached potentially eligible subjects were calculated. Data from 80 potentially eligible patients were analyzed. The types of ads that motivated contacts more frequently were social media (38.8%) and information provided to physicians from other hospitals (23.8%) (p=0,288). The frequencies of contacts motivated by publications on the internet (53%) and conventional strategies (47%) were similar. Facebook was the digital strategy associated with the higher number of contacts, followed by the hospital's website. Social networks and websites can be as effective as traditional methods of advertisement, in order to reach patients for stroke rehabilitation protocols. These results may have an impact on the planning of clinical trials, including studies that evaluate effects of rehabilitation interventions in patients with stroke.

A motion intention-based upper limb rehabilitation training system to stimulate motor nerve through virtual reality

Motor rehabilitation strategies for treating motor deficits after stroke are based on the understanding of the neural plasticity. In recent years, various upper limb rehabilitation robots have been proposed for the stroke survivors to provide relearning of motor skills by stimulating the motor nerve. However, several aspects including costing, human–robot interaction, and effective stimulation of motor nerve still remain as major issues. In this article, a new upper limb rehabilitation training system named as motion intention-based virtual reality training system is developed to close the aforementioned issues. The system identifies the user’s motion intention via force sensors mounted on the rehabilitation robot to conduct therapeutic exercises and stimulates the user’s motor nerve by introducing the illusion of immersion in virtual reality environment. The illusion of immersion is developed by creating Virtual Exoskeleton Robot model which is driven by user’s motion intention and reflecting the motion states in real time. The users can be present to the training exercises by themselves and fully engage in the virtual reality environment, so that they can relax, move, and recreate motor neuro-pathways. As preliminary phase, six healthy subjects were invited to participate in experiments. The experimental results showed that the motion intention-based virtual reality training system is effective for the upper limb rehabilitation exoskeleton and the evaluations of the developed system showed a significant reduction of the performance error in the training task.

Using Biophysical Models to Understand the Effect of tDCS on Neurorehabilitation: Searching for Optimal Covariates to Enhance Poststroke Recovery.

Stroke is a leading cause of worldwide disability, and up to 75% of survivors suffer from some degree of arm paresis. Recently, rehabilitation of stroke patients has focused on recovering motor skills by taking advantage of use-dependent neuroplasticity, where high-repetition of goal-oriented movement is at times combined with non-invasive brain stimulation, such as transcranial direct current stimulation (tDCS). Merging the two approaches is thought to provide outlasting clinical gains, by enhancing synaptic plasticity and motor relearning in the motor cortex primary area. However, this general approach has shown mixed results across the stroke population. In particular, stroke location has been found to correlate with the likelihood of success, which suggests that different patients might require different protocols. Understanding how motor rehabilitation and stimulation interact with ongoing neural dynamics is crucial to optimize rehabilitation strategies, but it requires theoretical and computational models to consider the multiple levels at which this complex phenomenon operate. In this work, we argue that biophysical models of cortical dynamics are uniquely suited to address this problem. Specifically, biophysical models can predict treatment efficacy by introducing explicit variables and dynamics for damaged connections, changes in neural excitability, neurotransmitters, neuromodulators, plasticity mechanisms, and repetitive movement, which together can represent brain state, effect of incoming stimulus, and movement-induced activity. In this work, we hypothesize that effects of tDCS depend on ongoing neural activity and that tDCS effects on plasticity may be also related to enhancing inhibitory processes. We propose a model design for each step of this complex system, and highlight strengths and limitations of the different modeling choices within our approach. Our theoretical framework proposes a change in paradigm, where biophysical models can contribute to the future design of novel protocols, in which combined tDCS and motor rehabilitation strategies are tailored to the ongoing dynamics that they interact with, by considering the known biophysical factors recruited by such protocols and their interaction.

Neurorehabilitation Topics in Patients with Multiple Sclerosis: From Outcome Measurements to Rehabilitation Interventions.

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system and the most common cause of nontraumatic disability in young adults. It is a heterogeneous disease associated with long-term disability, negatively influencing quality of life. Disease-modifying pharmacological therapies may decrease activity and progression of the disease, and symptomatic pharmacological treatments may reduce complaints to a certain extent; however, MS patients mostly still suffer from several neurologic deficits in the course of their disease. Consequently, specific comprehensive nonpharmacological rehabilitation interventions are needed to reduce disability to obtain better independence in activities of daily living, resulting in an optimal quality of life. Here the authors give an overview of the main sensorimotor symptoms in MS. Some of the most commonly used standardized outcome assessments are presented, and existing evidence-based motor rehabilitation strategies are described.

The effect of action observation/execution on mirror neuron system recruitment: an fMRI study in healthy individuals.

Action observation and execution activate regions that are part of the motor and mirror neuron systems (MNS). Using functional magnetic resonance (fMRI), we defined the presence and extent of MNS activation during three different motor tasks with the dominant, right-upper limb in healthy individuals. The influence of the modality of task administration (execution, observation, observation and execution) was also investigated. fMRI scans during the execution (E) of a motor task, the observation (O) of a video showing the same task performed by another person and the simultaneous observation and execution (OE) of the task were obtained from three groups of healthy subjects (15 subjects per group) randomized to perform: a simple motor (SM) task, a complex motor (CM) task and a finalistic motor (FM) task. Manual dexterity was assessed using the 9-hole peg test and maximum finger tapping frequency. MNS activation was higher during FM than SM or CM tasks, independently from the modality of administration (E, O, or OE). Inferior frontal gyrus recruitment was more significant during SM than CM tasks in the E and O conditions. Compared to SM and FM, CM task resulted in increased recruitment of brain regions involved in complex motor task performance. Compared to O and E, OE resulted in the recruitment of additional, specific, brain areas in the cerebellum, temporal and parietal lobes. The modality of administration and the type of task modulated MNS recruitment during motor acts. This might have practical implications for the set-up of individualized motor rehabilitation strategies.

Upper Limb Immobilisation: A Neural Plasticity Model with Relevance to Poststroke Motor Rehabilitation.

Advances in our understanding of the neural plasticity that occurs after hemiparetic stroke have contributed to the formulation of theories of poststroke motor recovery. These theories, in turn, have underpinned contemporary motor rehabilitation strategies for treating motor deficits after stroke, such as upper limb hemiparesis. However, a relative drawback has been that, in general, these strategies are most compatible with the recovery profiles of relatively high-functioning stroke survivors and therefore do not easily translate into benefit to those individuals sustaining low-functioning upper limb hemiparesis, who otherwise have poorer residual function. For these individuals, alternative motor rehabilitation strategies are currently needed. In this paper, we will review upper limb immobilisation studies that have been conducted with healthy adult humans and animals. Then, we will discuss how the findings from these studies could inspire the creation of a neural plasticity model that is likely to be of particular relevance to the context of motor rehabilitation after stroke. For instance, as will be elaborated, such model could contribute to the development of alternative motor rehabilitation strategies for treating poststroke upper limb hemiparesis. The implications of the findings from those immobilisation studies for contemporary motor rehabilitation strategies will also be discussed and perspectives for future research in this arena will be provided as well.

Residual Upper Arm Motor Function Primes Innervation of Paretic Forearm Muscles in Chronic Stroke after Brain-Machine Interface (BMI) Training.

BackgroundAbnormal upper arm-forearm muscle synergies after stroke are poorly understood. We investigated whether upper arm function primes paralyzed forearm muscles in chronic stroke patients after Brain-Machine Interface (BMI)-based rehabilitation. Shaping upper arm-forearm muscle synergies may support individualized motor rehabilitation strategies.MethodsThirty-two chronic stroke patients with no active finger extensions were randomly assigned to experimental or sham groups and underwent daily BMI training followed by physiotherapy during four weeks. BMI sessions included desynchronization of ipsilesional brain activity and a robotic orthosis to move the paretic limb (experimental group, n = 16). In the sham group (n = 16) orthosis movements were random. Motor function was evaluated with electromyography (EMG) of forearm extensors, and upper arm and hand Fugl-Meyer assessment (FMA) scores. Patients performed distinct upper arm (e.g., shoulder flexion) and hand movements (finger extensions). Forearm EMG activity significantly higher during upper arm movements as compared to finger extensions was considered facilitation of forearm EMG activity. Intraclass correlation coefficient (ICC) was used to test inter-session reliability of facilitation of forearm EMG activity.ResultsFacilitation of forearm EMG activity ICC ranges from 0.52 to 0.83, indicating fair to high reliability before intervention in both limbs. Facilitation of forearm muscles is higher in the paretic as compared to the healthy limb (p<0.001). Upper arm FMA scores predict facilitation of forearm muscles after intervention in both groups (significant correlations ranged from R = 0.752, p = 0.002 to R = 0.779, p = 0.001), but only in the experimental group upper arm FMA scores predict changes in facilitation of forearm muscles after intervention (R = 0.709, p = 0.002; R = 0.827, p<0.001).ConclusionsResidual upper arm motor function primes recruitment of paralyzed forearm muscles in chronic stroke patients and predicts changes in their recruitment after BMI training. This study suggests that changes in upper arm-forearm synergies contribute to stroke motor recovery, and provides candidacy guidelines for similar BMI-based clinical practice.

Combining Multiple Types of Motor Rehabilitation Enhances Skilled Forelimb Use Following Experimental Traumatic Brain Injury in Rats

Background. Neuroplasticity and neurorehabilitation have been extensively studied in animal models of stroke to guide clinical rehabilitation of stroke patients. Similar studies focused on traumatic brain injury (TBI) are lacking. Objective. The current study was designed to examine the effects of individual and combined rehabilitative approaches, previously shown to be beneficial following stroke, in an animal model of moderate/severe TBI, the controlled cortical impact (CCI). Methods. Rats received a unilateral CCI, followed by reach training, voluntary exercise, or unimpaired forelimb constraint, alone or in combination. Forelimb function was assessed at different time points post-CCI by tests of skilled reaching, motor coordination, and asymmetrical limb use. Results. Following CCI, skilled reaching and motor coordination were significantly enhanced by combinations of rehabilitation strategies, not by individual approaches. The return of symmetrical limb use benefited from forelimb constraint alone. None of the rehabilitation strategies affected the size of injury, suggesting that enhanced behavioral function was not a result of neuroprotection. Conclusions. The current study has provided evidence that individual rehabilitation strategies shown to be beneficial in animal models of stroke are not similarly sufficient to enhance behavioral outcome in a model of TBI. Motor rehabilitation strategies for TBI patients may need to be more intense and varied. Future basic science studies exploring the underlying mechanisms of combined rehabilitation approaches in TBI as well as clinical studies comparing rehabilitation approaches for stroke versus TBI would prove fruitful.

Mental practice: applying motor PRACTICE and neuroplasticity principles to increase upper extremity function.

The vast majority of stroke survivors exhibit residual impairments,1,2 with most reporting-associated quality of life decrements.3,4 The prevalence of these poststroke motor deficits and the overall burden of stroke are likely to rise exponentially attributable to an aging population and increases in the prevalence of many risk factors (eg, obesity, diabetes mellitus, smoking).5,6 In light of these trends, several promising motor interventions have been introduced, with many targeting upper extremity (UE) hemiparesis, given its widely appreciated impact. Yet, although several of these approaches appear efficacious, few therapeutic approaches showing promise in animal or early human trials are fully translated to regular clinical practice.7 Consistently, many contemporary motor rehabilitation strategies require high duration contact time8 and costly equipment,9 preventing their widespread clinical application, except among specialized rehabilitation and academic medical centers. Mental practice involves repetitive cognitive rehearsal of physical movements in the absence of physical, voluntary attempts. From a practical perspective, mental practice constitutes an attractive alternative to other rehabilitative approaches because it does not require physical rehearsal, can be performed without direct supervision, and requires minimal expense and equipment, facilitating ease of use. The brain’s ability to respond to repetitive, learning-based strategies even years after injury and well into adulthood also makes mental practice a favorable match for stroke, which tends to be a disease of the aged and because survivors frequently exhibit residual impairments for years postictus. We speculated that repetitive mental practice use, shown to trigger the same neural areas and musculature as physical practice of the same tasks,10–14 would cause substantive neural and motor changes in stroke survivors with UE deficits. Although used for decades in sport and exercise settings, this laboratory was the first to apply mental practice to increase learning …

Non-invasive Cerebellar Stimulation—a Consensus Paper

The field of neurostimulation of the cerebellum either with transcranial magnetic stimulation (TMS; single pulse or repetitive (rTMS)) or transcranial direct current stimulation (tDCS; anodal or cathodal) is gaining popularity in the scientific community, in particular because these stimulation techniques are non-invasive and provide novel information on cerebellar functions. There is a consensus amongst the panel of experts that both TMS and tDCS can effectively influence cerebellar functions, not only in the motor domain, with effects on visually guided tracking tasks, motor surround inhibition, motor adaptation and learning, but also for the cognitive and affective operations handled by the cerebro-cerebellar circuits. Verbal working memory, semantic associations and predictive language processing are amongst these operations. Both TMS and tDCS modulate the connectivity between the cerebellum and the primary motor cortex, tuning cerebellar excitability. Cerebellar TMS is an effective and valuable method to evaluate the cerebello-thalamo-cortical loop functions and for the study of the pathophysiology of ataxia. In most circumstances, DCS induces a polarity-dependent site-specific modulation of cerebellar activity. Paired associative stimulation of the cerebello-dentato-thalamo-M1 pathway can induce bidirectional long-term spike-timing-dependent plasticity-like changes of corticospinal excitability. However, the panel of experts considers that several important issues still remain unresolved and require further research. In particular, the role of TMS in promoting cerebellar plasticity is not established. Moreover, the exact positioning of electrode stimulation and the duration of the after effects of tDCS remain unclear. Future studies are required to better define how DCS over particular regions of the cerebellum affects individual cerebellar symptoms, given the topographical organization of cerebellar symptoms. The long-term neural consequences of non-invasive cerebellar modulation are also unclear. Although there is an agreement that the clinical applications in cerebellar disorders are likely numerous, it is emphasized that rigorous large-scale clinical trials are missing. Further studies should be encouraged to better clarify the role of using non-invasive neurostimulation techniques over the cerebellum in motor, cognitive and psychiatric rehabilitation strategies.