Neuromodulation: Technology at the Neural Interface

Low-intensity focused ultrasound (LIFU) is a non-invasive neuromodulation technique with a favorable safety profile in healthy volunteers. Participant-experienced symptoms however remain inconsistently measured, and prospective benchmarks are lacking. Here, we prospectively characterized symptoms associated with LIFU neuromodulation across eight studies using a standardized Report of Symptoms (ROS). We compiled 629 sessions (472 LIFU, 157 sham) in 106 healthy adults (28.1 +/- 9.8 years) across eight cortical and subcortical targets (500 kHz; extracranial ISPPA 3.9-33.3 W/cm2; mechanical index 0.5-1.4). The ROS rated 17 symptom domains from 0 (absent) to 3 (severe) before and after each session. New-onset incidence, symptom severity, and total symptom burden were compared between LIFU and sham. The same instrument was applied in 35 patients with chronic pain. Symptom profiles after LIFU were indistinguishable from sham across all 17 domains. Total symptom burden averaged approximately one domain per session and did not increase after LIFU (0.94 to 1.03; p = 0.120). Post-intervention burden was predicted by baseline burden (beta = 0.347, p < 0.001) but not by stimulation condition (p = 0.222). New-onset symptoms did not increase across up to 27 LIFU sessions (OR = 0.99, p = 0.73) and were weakly, non-significantly related to acoustic intensity (rho = 0.37). Across a prospective, sham-controlled dataset, LIFU added no measurable symptom burden and was well tolerated in healthy adults, with comparable tolerability in patients. These findings establish a benchmark for the safety of human LIFU neuromodulation and a foundation for its therapeutic translation.

Background: Deep brain stimulation (DBS) is a widely used therapy for neurologic and psychiatric disorders. Conventional DBS delivers highly regular stimulation patterns that suppress pathological activity but can induce stimulation-related side effects, limiting the therapeutic window. Introducing controlled temporal variability through stochastic pulse timing may represent an alternative programming dimension to improve tolerability while preserving clinical benefit. Methods: An adult in their 60's with bilateral Vim DBS underwent evaluation of tonic, pink-noise, and white-noise stimulation patterns delivered through his chronically implanted Boston Scientific Genus system using the Chronos research platform. We assessed tremor and stimulation-induced side effects using accelerometry, spiral drawing tasks, standardized speech recordings, and patient-reported paresthesias. Results: Pink noise stimulation preserved meaningful tremor suppression while improving tolerability compared with conventional tonic 130 Hz stimulation. Under tonic stimulation, dysarthria and paresthesias were prominent at 2.0 mA, narrowing the usable therapeutic window. In contrast, pink noise maintained tremor control across the same amplitude range with reduced side-effect burden. White noise stimulation demonstrated intermediate effects, providing improved tolerability relative to tonic stimulation but less tremor suppression than pink noise. Findings were consistent across accelerometry and functional drawing tasks. Conclusion: This study provides first-in-human evidence that temporally structured stochastic pulse timing can preserve therapeutic benefit while expanding the tolerable stimulation range relative to tonic DBS. These findings suggest that temporal structure represents a clinically meaningful programming dimension that may broaden the DBS therapeutic window using software based updates to existing hardware. Further evaluation in larger cohorts is warranted

Background: Low-intensity focused ultrasound (LIFU) is an emerging noninvasive neuromodulation technique capable of targeting deep cortical and subcortical structures with high spatial precision. In healthy human volunteers, LIFU has demonstrated a favorable safety and tolerability profile across multiple studies. However, its safety and tolerability in clinical populations remains poorly characterized, representing a critical barrier to clinical translation. Here, we prospectively evaluate the safety and tolerability of LIFU targeting the left dorsal anterior insula (dAI) in patients with fibromyalgia (FM). Methods: In a single-blind, sham-controlled, within-subjects crossover design, 13 individuals with FM (43.1 +/- 13.2 years; 12 female) received 10 minutes of active LIFU (500 kHz, 1 kHz PRF, 36% duty cycle, 4.2 W/cm2 Isppa; 100 x 1-second pulse trains with a 5-second inter-train interval) targeting the left dorsal anterior insula (dAI) or sham on separate visits. Safety was evaluated through neuroradiological review of post vs. pre LIFU FLAIR MRI, quantitative voxel-wise FLAIR analysis, and patient report of symptoms (ROS). Tolerability was assessed using an experience assessment. Efficacy of the LIFU intervention was assessed using quantitative sensory testing (QST) including temporal summation of pain (TSP) and conditioned pain modulation (CPM). Results: Neuroradiological review identified no new evidence of edema, microhemorrhage, acute ischemia, or white matter injury on post-LIFU structural imaging. Quantitative FLAIR analysis using contralateral-mirror-referenced relative FLAIR (rFLAIR) showed no significant within-subject change in the stimulated beam volume (delta rFLAIR = 0.002 +/- 0.025, t(12) = 0.30, P = 0.769, Cohen's dz = 0.08). No serious adverse events were documented and ROS indicated no change due to LIFU sonication. Participants rated the procedure as comfortable and could not distinguish active from sham LIFU. LIFU did not result in statistically significant changes for TSP (p = 0.797) or CPM (p = 0.465). Conclusions: Ten minutes of LIFU targeting the left dAI was safe and well tolerated in individuals with FM, with no neuroradiological or quantitative MRI evidence of tissue effects and no serious adverse events. Blinding was preserved, and participants rated the procedure as comfortable. Although no significant changes were observed in experimental pain measures, these findings support the feasibility of targeting deep salience and pain amplification circuitry with LIFU in patients with FM and provide a foundation for adequately powered efficacy trials.

IntroductionVagus nerve stimulation modulates laryngeal, cardiac, pulmonary, and gastrointestinal functions. Knowledge of where along the vagal trunk organ-specific branches emerge may support alternative surgical placements of stimulation devices to engage targeted functions while avoiding off-target effects. However, no quantified map of how vagal branches emerge and how they relate to surgically relevant anatomical landmarks exists in humans. MethodsFifty-eight vagus nerves (29 left, 29 right) from 29 embalmed donor bodies (15 females) were dissected from the jugular foramen through the thoracic cavity. Branches were traced to end organs and allocated to seven groups -- sympathetic, muscular, vascular, cardiac, pulmonary, esophageal, and multiple targets -- and several sub-groups. Distances between branch emergence and the jugular foramen (JF) were normalized to three anatomical landmarks: carotid bifurcation, laryngeal prominence, and superior border of clavicle. ResultsBranch emergence follows a proximal-to-distal order: sympathetic (5.28 cm from JF), muscular (9.59 cm), vascular (10.70 cm), cardiac (19.65 cm), pulmonary (25.36 cm), and esophageal (26.57 cm). Vagal branches emerge into two embryological domains separated near the clavicle: pharyngeal arch-targeting branches cluster proximally (9.34 cm) and primitive mediastinum-targeting branches cluster distally (23.74 cm), with sympathetic, muscular, and vascular sub-groups occupying distinct zones within the proximal domain. The largest branch-free intervals occur above the left clavicle (2.33 {+/-} 2.80 cm) and below the left carotid bifurcation (2.58 {+/-} 3.17 cm). Alternate placement regions separating targeted organs from off-targets: sympathetic vs. cervical visceral at 6/8 cm (L/R), cardiac vs. carotid sinus/bifurcation at 14/10 cm, and recurrent laryngeal vs. other cervical visceral at 18/13 cm from JF. Overall, no differences were found between male and female donors. ConclusionsThis study provides a quantified, landmark-registered map of cervical and thoracic vagal branch emergence, offering a standardized anatomical template that may inform strategies for more function-selective vagal neuromodulation.

BackgroundAcute postoperative pain remains a major clinical therapeutic challenge. Current peripheral nerve blockade (PNB) techniques are effective for some patients but are limited by invasiveness, short duration, reliance on highly trained providers, and off-target motor and sensory effects. Focused ultrasound (FUS) is a novel neuromodulatory technology with the potential to achieve noninvasive, selective, reversible, and prolonged inhibition of peripheral nociceptive fibers to prevent and treat acute pain. We hypothesized that noninvasive transcutaneous targeting of the rat sciatic nerve using co-aligned diagnostic ultrasound (dUS) and FUS transducers could produce selective and reversible inhibition of nociceptive pain behaviors while preserving motor and non-nociceptive sensory functions. MethodsIn an in vivo rat hindpaw incisional (HPI) pain model, using a novel, transcutaneous dUS-guided FUS system, the sciatic nerve was located with dUS, and FUS energy was applied to it just prior to hindpaw incision. FUS parameters were iteratively adjusted to achieve reversible, selective inhibition of nociceptive behaviors without changing motor and non-pain sensory behaviors. Animals were randomized into six groups: No Intervention (Control), HPI Only (Disease Control), Sham FUS, FUS Only, FUS+HPI (Intervention), and LA+HPI (Positive Control). Primary outcomes were changes in nociceptive sensory functions, assessed by thermal and mechanical sensitivity. Secondary outcomes were changes in non-nociceptive sensory and motor functions, assessed by hindpaw flexion and extension reflexes. ResultsCompared with the HPI Only group, the FUS+HPI group demonstrated (1) significant attenuation of hindpaw thermal hypersensitivity from day 0 - week 5.0 and week 8.0 - 16.0 (p < 0.05-0.001); (2) significant attenuation of mechanical hypersensitivity from day 0 until week 4.0 (p < 0.05-0.001); (3) no significant attenuation of flexion; and (4) no significant attenuation of extension. ConclusionsTranscutaneous dUS-guided FUS enables selective, reversible inhibition of A{delta} and C nociceptive fiber mediated behaviors while sparing A motor and A{beta} sensory behaviors. FUS-induced PNB prevented both acute and persistent pain behaviors. These findings support FUS as a promising noninvasive peripheral nerve blockade strategy for acute pain management.

Myofascial pain syndrome (MPS) is a major cause of chronic neck pain, with tissue ischemia implicated as a contributing factor. This prospective, single-arm interventional study evaluated the analgesic effect of ultrasound-guided fascia hydrorelease (US-FHR) performed around arteries supplying the neck in patients with chronic neck MPS. Thirteen adults (median age 53.0 years; 38.5% female) underwent US-FHR targeting the perivascular fascia of either the transverse cervical or dorsal scapular artery using 2 mL of normal saline. Pain intensity was assessed by visual analog scale (VAS) at rest and during movement; disability by the 5-item Pain Disability Index, Japanese version (PDI-5-J); and arterial blood flow volume before and after the procedure. The primary outcome, pain VAS during movement, decreased from 49.0 mm (interquartile range [IQR], 44.5-64.0) at baseline to 22.0 mm (IQR, 14.5-31.5) at 15 min and 22.0 mm (IQR, 14.0-34.0) at 1 week (Hodges&-Lehmann median difference, 30.5 mm [95% CI, 24.5 to 36.5] and 28.5 mm [95% CI, 18.5 to 37.0]; both P < 0.001). Pain VAS at rest improved from 21.0 mm (IQR, 13.0-43.5) to 8.0 mm at 15 min and 1 week (median difference, 14.5 mm [95% CI, 9.0 to 24.0; P = 0.001] and 13.5 mm [95% CI, 6.0 to 21.0; P = 0.007]). PDI-5-J decreased from 17.0 (IQR, 10.5-23.0) to 13.0 (IQR, 4.0-17.5) at 1 week (median difference, 5 [95% CI, 2 to 8; P = 0.004]). Blood flow volume increased from 11.2 mL/min (IQR, 4.5-14.4) to 17.2 mL/min (IQR, 6.1-23.7) immediately after US-FHR (median difference, +4.1 mL/min [95% CI, +2.5 to +8.9; P = 0.001]), although transient. One patient experienced transient bleeding that was promptly controlled. In this single-arm feasibility study, US-FHR around the target artery was simple and safe to perform and was associated with reduced neck pain. Because the study lacked a control group, these preliminary findings should be regarded as hypothesis-generating and require confirmation in controlled trials; they may also inform the future evaluation of MPS in other anatomical regions. Trial registration: UMIN Clinical Trials Registry, UMIN000053612.

Background: Generalized anxiety disorder (GAD) is associated with substantial psychological burden, autonomic dysregulation, and limitations of existing pharmacological and psychotherapeutic treatments. Transcutaneous auricular vagus nerve stimulation (taVNS) has emerged as a promising non-invasive neuromodulation approach, but evidence regarding home-based application in GAD remains limited. Objective: To evaluate the feasibility, safety, and preliminary clinical and physiological outcomes of a home-based taVNS intervention in adults with psychologist-confirmed moderate-to-severe GAD. Methods: In this prospective single-arm feasibility study, 48 participants initiated a 4-week home-based taVNS intervention consisting of two daily stimulation sessions performed five days per week. Clinical assessments were conducted at baseline, Week 2, Week 4, and follow-up visits at Weeks 6 and 8. Ambulatory electrocardiographic monitoring was performed before treatment initiation, at Week 2, and at the end of treatment to assess heart rate variability (HRV) using the root mean square of successive differences (RMSSD). Primary outcomes included feasibility, safety, adherence, and change in clinician-rated anxiety severity (HAM-A). Results: Thirty-four participants completed the study and were included in the primary analyses. HAM-A scores decreased significantly from baseline to Week 4 ([EMD] -6.9, 95% CI -10.4 to -3.4, p = 0.001), with partial maintenance during follow-up. Improvements were also observed in Beck Anxiety Inventory scores, whereas changes in GAD-7, perceived stress, depressive symptoms, and sleep quality were not statistically significant. RMSSD increased significantly from baseline to Week 4 (EMD 6.7 ms, 95% CI 2.1-11.3, p = 0.009). Greater increases in RMSSD were associated with larger reductions in HAM-A (R^2 = 0.18, p = 0.031) and BAI scores (R^2 = 0.21, p = 0.019). No serious adverse events occurred. Mean adherence was 79.8%, and 73.5% of participants completed at least 70% of prescribed stimulation sessions. Conclusions: Home-based taVNS was feasible and generally well tolerated in adults with moderate-to-severe GAD. Preliminary improvements in clinician-rated anxiety severity and autonomic physiological measures were observed; however, the single-arm design precludes causal inference. These findings support further evaluation of home-based taVNS in adequately powered randomized sham-controlled trials.

This research demonstrates that the trans-aqueduct approach is a feasible, minimally invasive access pathway to the third ventricle, offering a potential route to the deep brain for therapeutic technologies. Further pre-clinical investigation is required to thoroughly evaluate physiological tolerance, trauma risk, and the long-term implications of intraventricular implantation. The third ventricle is a high-value site for neuromodulation due to its proximity to deep-brain targets, including the subthalamic nucleus (STN) and globus pallidus internus (GPi). This study defined the anatomical pathway; and evaluated the technical feasibility of retrograde access to the third ventricle via the cerebral aqueduct using minimally invasive interventional techniques. Evaluation was conducted in three phases using human MRI datasets (n=16; mean age 48.4 years) and cadaveric specimens (n=6; mean age 88.2 years). Phase 1 involved morphometric MRI analysis of the aqueduct and ventricles. Phase 2 tested trans-aqueduct access on cadaver specimens via fluoroscopically guided guidewires and catheters. Phase 3 utilized direct anatomical dissections on cadaver specimens (n=3) to morphometrically measure the third ventricular cavity and its relationship to deep-brain nuclei. Measurements across the sample groups showed a mean aqueduct diameter of 1.6 mm (SD=0.14). Third ventricle dimensions averaged 27.6 mm (ventral-dorsal), 19.9 mm (caudal-cranial), and 5.7 mm (lateral). Successful access to the third ventricle was achieved in 83% (5/6) of cadaveric specimens. The optimal technical configuration utilized a 0.018'' angled-tip guidewire and 5-6 Fr catheters; the aqueduct accommodated diameters up to 2.0 mm with minimal resistance. The STN and GPi were localized within 5-20 mm of the ventricular volumetric centroid. The trans-aqueduct approach is a technically feasible, minimally invasive pathway for accessing the third ventricle. This route offers a potential alternative for the delivery of therapeutic neurotechnologies. Further research is required to assess physiological tolerance, trauma risk, and the long-term safety of intraventricular implantation.

Background: Transcranial temporal interference stimulation (tTIS) is an emerging noninvasive neuromodulation approach that enables focal, frequency-specific modulation of deep brain regions, offering a novel method for investigating therapeutic mechanisms underlying brain and mental health disorders. Pain is a key target because it is a feature of multiple disorders and is increasingly understood to depend on brain circuits. Here, we tested the effects of tTIS on bilateral evoked pain, capitalizing on converging evidence from human and animal studies indicating that the primary motor cortex (M1) contains body-wide inter-effector regions and has descending projections to regions implicated in nociceptive, motivational, and autonomic processing, making it a key cortical target for pain modulation. Methods: We conducted a pre-registered, triple-blind, randomized crossover study (N = 32, 160 study sessions), investigating frequency-dependent effects of tTIS applied to the left M1 on experimentally evoked thermal pain in healthy adults. We tested four stimulation frequencies (10 Hz, 20 Hz, 70 Hz, and sham) on separate days (>10,000 pain trials total). Noxious heat was applied to both the right and left forearms using individually calibrated temperatures both pre- and post-stimulation. Results: Active tTIS produced significant analgesia at all stimulation frequencies (10 Hz, 20 Hz, and 70 Hz) relative to sham (Cohens d = 0.46-0.82, all p < 0.05). 10 Hz produced the greatest reduction (d = 0.82), and both 10 Hz and 20 Hz produced more analgesia than 70 Hz (d = 0.44 and 0.38, respectively; p < 0.05). Stimulation-related sensations were equivalent across frequencies, and participants were blind to condition. Pain reductions remained stable over a [~]40-min post-stimulation period and were bilateral, consistent with stimulation of body-wide inter-effector regions. Conclusions: These results provide the first evidence that tTIS can reliably reduce experimental pain perception in humans in a frequency-dependent manner, providing a foundation for noninvasive pain modulation with tTIS.

ObjectiveNeurogenic lower urinary tract dysfunction (NLUTD) impairs bladder control and remains difficult to treat. We aim to define how electrical stimulation (ES) parameters of the external urethral sphincter (EUS) affect urinary leakage thresholds to guide neuromodulation strategies for NLUTD. MethodsWe performed direct EUS stimulation in anesthetized rats using charge-balanced biphasic pulses while systematically varying current amplitude (0.5-3.0 mA), frequency (20-100 Hz), and pulse duration (0.5-3 ms). Urine leakage thresholds were mapped across the multidimensional parameter space. ResultsStimulation parameters exhibited strong nonlinear interdependence in determining leakage onset. At a fixed pulse duration, higher current amplitudes required lower stimulation frequencies to evoke leakage. Increasing pulse duration substantially reduced both current and frequency thresholds. Age and sex caused modest shifts in absolute thresholds but did not alter the fundamental parameter-response relationships. ConclusionPulse duration, current amplitude, and frequency jointly govern urinary leakage thresholds, with pulse duration serving as the dominant modulator of stimulation efficiency. SignificanceThis work establishes a quantitative framework for charge-efficient stimulation parameter selection, enabling the design of energy-aware, precision neuromodulation protocols and implantable systems for NLUTD rehabilitation.

Parkinsons disease patients may experience a different therapeutic effect after replacement of the Medtronic Activa(R) deep brain stimulation neurostimulator with the newer Percept model, which features multiple independent current sources and constant-current control. We analyzed patient-reported therapeutic effect changes after Activa(R)-to-Percept replacements (AP, n=52) across six Dutch DBS-centers, comparing appropriate (AP+, n=36) and inappropriate/no (AP-, n=16) use of the manufacturers replacement workflow. Previous Activa(R)-to-Activa(R) replacements (AA, n=69) were used as reference. Worsened therapeutic effect was reported in 75.0% of AP-, 44.4% of AP+, and 21.7% of AA replacements (p<0.001). In the AP group, most patients with worsened effect were previously programmed with constant-voltage. Concluding, the risk of worsened therapeutic effect following AP replacements is higher compared to AA replacements, in particular when the replacement workflow is not properly used or in complex electrode configurations. We advise to use the workflow, inform the patient and plan closer follow-up appointments.

PurposeTranscranial direct current stimulation (tDCS) can noninvasively modulate activity in targeted brain regions. It is well established that the excitability of motor-related regions can increase when the target region is located beneath the anode (anodal tDCS), suggesting its potential to increase motor performance. Although such attempts have been widely examined, the results remain inconclusive. The purpose of this study was to assess the conditions under which anodal tDCS may improve motor performance in healthy adults. MethodsWe conducted a systematic review of studies on the use of anodal tDCS for improving motor performance in healthy adults. A computerized search was performed using the Web of Science, Scopus, PubMed, JDreamIII, and Ichushi-Web to identify relevant studies published between January 1, 1990 and May 25, 2022. ResultsTwenty-five studies were included in the qualitative synthesis. For the meta-analysis, 25 trials (N=885) were extracted from 23 studies. There were significant effects of anodal tDCS on motor performance improvement, but with evidence of publication bias and substantial heterogeneity among the trials. Post-hoc analysis revealed that motor performance 24 hours after the application of anodal tDCS may benefit from stimulation. There was no marked effect related to stimulation intensity, duration, or whether stimulation was provided during motor performance. ConclusionsOur study clarified the current state of anodal tDCS use for motor performance enhancement and indicates that there is currently no reliable evidence to support its effectiveness. Further studies, particularly randomized controlled trials, are necessary to establish the reliability of these effects for future applications.

Background: Thalamic low-intensity transcranial focused ultrasound (tFUS) has shown promise for increasing behavioral responsiveness in disorders of consciousness (DOC), but no study has examined whether it can causally modulate the well-validated behavioral, electrophysiological, and metabolic biomarkers of DOC impairment. Methods: Sixteen adult patients (44% Female; Age, M=37.81, SD=15.97) with a chronic DOC (Time Since Injury, M=3.39, SD=1.94 years) secondary to severe brain injury (TBI 44%, non-TBI 56%) underwent a 10-day inpatient, longitudinal, single-arm, open-label protocol. tFUS was delivered in a single session targeting the left central thalamus. Well-known behavioral (CRS-R), electrophysiological (EEG {delta}/{beta} ratio), metabolic (18F-FDG PET), and polysomnographic outcomes were assessed at baseline and after sonication. Results: The maximum CRS-R total score increased significantly following tFUS compared to baseline (M=13.27 vs. M=10.33; t(14)=7.407, p<0.001, d=1.913), as did the global EEG {delta}/{beta} ratio (N=14; W=17, p=0.025, r=0.68), with the degree of frontal slowing positively predicting behavioral gains ({tau}b=0.51, p=0.016). Glucose metabolism decreased bilaterally in thalamus and frontal, temporal, and parietal cortices at both post-tFUS timepoints compared to baseline. Finally, N2 sleep increased by 33% following tFUS (N=11; t(10)=2.386, p=0.038, d=0.72), though this did not survive correction. No severe adverse events were observed. Conclusion: Thalamic tFUS can causally modulate well-validated behavioral, electrophysiological, and metabolic biomarkers of DOC. The convergent inhibitory signature across these measures suggests a thalamocortical reset mechanism, complementing existing excitatory neuromodulation approaches and providing the mechanistic foundation for a large, randomized sham-controlled trial.

ObjectiveVagus nerve stimulation (VNS) is an established neuromodulation therapy used in the management of drug-resistant epilepsy (DRE), or when other intracranial surgical modalities have not reduced seizure burden. We evaluated whether prior intracranial surgery for epilepsy influences safety and effectiveness outcomes with adjunctive VNS, using real-world data from the CORE-VNS study. MethodsCORE-VNS (NCT03529045), a prospective, multicenter, international observational study, was designed to collect data on seizure and non-seizure outcomes in patients with DRE treated with VNS. Participants were identified as having or not having undergone prior intracranial brain surgery for epilepsy (ICSE) and received an initial VNS implant. Baseline seizure frequency data and patient-reported outcome measures were collected at 3, 6, 12, 24, and 36 months. This analysis compared the baseline data for VNS therapy and safety outcomes at 36 months. ResultsAmong 531 participants implanted with VNS, prior ICSE was performed in 84. Median percentage seizure reductions at 36 months for all seizures (76.6% and 76.3%), all focal seizures (83.3% and 71.8%), and all generalized seizures (77.8% and 76.2%) were found to be similar between those without and with a history of ICSE, respectively. The 50% responder rate for all seizures reported at baseline was similar, 64.8% and 61.8%, in both groups and complete seizure freedom was reported by 17.9% and 8.8%, respectively. Implant-related adverse events (AE) and serious AE rates were similar between groups. ConclusionVNS was associated with clinically meaningful seizure reductions and showed a consistent safety profile irrespective of the history of ICSE. Prior ICSE should not be a contraindication to the consideration of VNS.

ObjectiveLateral spinal cord stimulation (LSCS) is a promising approach for restoring somatosensory feedback in lower-limb amputees, but its spatial selectivity remains limited. Percepts often spread to unintended regions of the residual limb, and reducing electrode contact size may not improve focality. This study investigated whether the anatomical organization of lumbar dorsal rootlets (DR) imposes fundamental constraints on LSCS selectivity. ApproachAcute neurophysiology experiments were performed in six adult cats. Both LSCS and individual DR stimulation were conducted in the same animals. For DR stimulation, bipolar hook electrodes were used to stimulate individual DR, while antidromic compound action potentials (CAPs) were recorded from femoral and sciatic nerve branches instrumented with nerve cuffs. For LSCS, custom 32-contact epidural paddle electrodes were placed over the lateral surface of the spinal cord at corresponding vertebral levels. Recruitment thresholds, dynamic ranges, and response patterns were analyzed across spinal levels, and DR recruitment patterns were directly compared to those evoked by LSCS within the same animals. Main resultsA clear rostrocaudal organization was observed across spinal levels during stimulation of individual DR, with femoral branches predominantly recruited at L4-L5 and sciatic branches at L6-L7. However, no somatotopic organization was found across DR within each spinal level; individual DR frequently co-activated multiple branches within the same group, and selective recruitment could only be maintained over a narrow dynamic range (median [~]10 {micro}A). LSCS exhibited even a narrower dynamic range ([~]5 {micro}A) but closely mirrored DR recruitment patterns, indicating that LSCS activates sensory afferents in a manner determined by the organizational structure of the DR. SignificanceThese findings demonstrate that the limited spatial selectivity of LSCS can largely be attributed to the coarse organization of DR within each root level rather than due to limitations of epidural electrode design. Moving electrodes intradurally or reducing contact size further is unlikely to substantially improve focality. Instead, improving paddle stability to ensure consistent placement over the appropriate spinal levels may be a more effective strategy for enhancing percept localization.

Background: Chronic pain is a multidimensional condition that often persists despite conventional treatment and adversely affects multiple domains of daily life. Music listening has emerged as a promising non-pharmacological intervention, with accumulating evidence supporting its beneficial effects on pain and associated psychological outcomes. However, despite growing evidence of efficacy, the translation of music listening into routine clinical practice remains limited, partly because intervention reporting has received comparatively little attention. Objective: To evaluate the effectiveness of music listening interventions for chronic pain and systematically assess the methodological quality and completeness of intervention reporting to identify barriers to reproducibility and clinical implementation. Methods: Systematic searches were conducted in PubMed, Cochrane Library, CINAHL, and Web of Science through June 2025, with no date restrictions on publication. Randomized controlled trials involving adults with chronic pain receiving music listening interventions were included. Two independent reviewers screened studies, extracted data, and assessed risk of bias. Intervention reporting was evaluated using the TIDieR checklist, and a random-effects meta-analysis was performed for pain intensity outcomes. Results: Ten RCTs involving 538 participants were included. Music listening interventions varied substantially in delivery, duration, and music selection procedures, reflecting considerable heterogeneity in intervention design. Most studies reported significant improvements in pain and psychological outcomes. Meta-analysis of eight trials (10 effect estimates), demonstrated a moderate reduction in pain intensity (SMD = -0.53, 95% CI: -0.96 to -0.11, p = 0.014; I2 = 76.2%). Although intervention rationale and procedures were generally well described, reporting of intervention modifications, treatment fidelity, and adherence was frequently incomplete. These reporting deficiencies may compromise reproducibility and limit translation into clinical practice. Conclusions: Music listening appears to be a safe, accessible, and scalable non-pharmacological intervention for chronic pain management, with benefits extending beyond pain reduction to psychological wellbeing, quality of life, and functioning. However, incomplete reporting of key intervention components may limit reproducibility and hinder clinical implementation. Future trials should adopt standardized and transparent reporting standards to facilitate implementation into clinical practice.

ObjectiveTo address the limitations of current trial-and-error programming strategies in deep brain stimulation (DBS) for refractory obsessive-compulsive disorder (OCD), we implanted patients with sensing-capable DBS devices to identify neural biomarkers that could provide objective feedback to the clinician about therapeutic efficacy. MethodsWe conducted an early feasibility study in 10 patients with severe, treatment-resistant OCD. All subjects received bilateral DBS leads targeting the ventral internal capsule (VC) and the second half of the cohort also received strip electrodes over the bilateral orbitofrontal cortex for recording only. All leads were connected to investigational, bidirectional DBS devices. After implantation, participants returned for scheduled programming visits to determine optimal stimulation parameters (Phase 1). In Phase 2, patients completed a course of exposure and response prevention (ERP) psychotherapy, and in Phase 3, patients underwent a double-blind discontinuation of DBS to test true vs. sham response. Phase 4 was an open-label follow-up. We administered standardized symptom scales throughout the study and used non-parametric repeated-measures analyses to analyze neuropsychological data. ResultsAll patients elected to resume stimulation after a discontinuation phase. At the end of the study, the mean reduction in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was 22 points or 60% across all patients with 8 patients demonstrating full response (>35% decrease in Y-BOCS). All participants also experienced reduced depression severity. ConclusionsIn patients with refractory OCD, we demonstrate excellent clinical response to VC DBS. We show feasibility of recording neural data both at home and in the clinic on board bidirectional DBS devices.

Transcranial temporal interference stimulation (tTIS) is a promising non-invasive brain stimulation technique that has the potential to selectively modulate deep brain regions by delivering two high-frequency alternating currents that interfere to produce a low-frequency amplitude-modulated envelope at the target. A key challenge in deploying tTIS is finding electrode current patterns that are simultaneously effective, focal, and safe. This is a fundamentally non-convex optimization problem for which a number of methods have recently been proposed. However, no systematic comparison of these methods across a large and diverse set of brain targets has been performed, leaving practitioners without clear guidance on how best to optimize for a particular experimental setting. In this work, we present a comprehensive benchmarking study comparing seven tTIS optimization methods that have appeared in the literature in recent years: exhaustive search, genetic algorithm, multi-objective evolutionary algorithm (MOVEA), min-max optimization, convex TI (CVXTI), non-convex optimization with convex relaxations, and an unsupervised neural network. All methods were evaluated across 250 brain targets spanning cortical and subcortical gray matter and white matter regions in five finite element head models. Each method was evaluated on two key metrics: mean electric field strength within the target region of interest, and off-target stimulated brain volume. Results were stratified by tissue type and target depth to identify systematic performance differences. Based on these results, we provide practical evidence-based recommendations for optimization method selection among these seven methods depending on target location, tissue type, and available computation time. Moreover we provide the code base that will allow other investigators to use these methods for their own applications. Our goal is to provide researchers and clinicians with a clear, evidence-based framework for choosing a tTIS optimization method suited to their specific target and application.

The anterior cingulate cortex (ACC) is a key brain center involved in cognitive and emotional processing that is implicated in a variety of neuropsychiatric disorders including chronic pain and depression. Circuit-targeted diagnosis and treatment of these disorders will require the capacity to precisely modulate ACC subregions. Toward that end, we recently developed and validated a novel low-intensity transcranial focused ultrasound device that can noninvasively and directly modulate ACC subdivisions in humans with millimeter precision. Here we describe the subjective reports of 36 individuals diagnosed with either chronic pain or major depression who received repeated brief stimulation trials (807 active, 797 sham; duration 30s-3min) spanning the dorsoventral extent of the ACC. Sonication immediately altered cognitive-emotional states (odds ratio 5.6, active versus sham), eliciting a positive-valence experience more often than negative (29% versus 8%) in both diagnostic groups. Sham-adjusted response rate varied across ACC targets, with the largest effects (Cohen's d ~ 0.8) observed in pregenual and subgenual ACC in subjects with chronic pain and depression, respectively. These rapid trial-by-trial responses to ACC stimulation predicted subsequent improvements in pain and depression severity at 24 hours. Collectively, these findings reveal that transcranial ultrasound can robustly evoke immediate, target-specific, clinically meaningful changes in cognitive-emotional state, demonstrating the potential of ultrasonic neuromodulation as a tool for individualized probing of circuit function and dysfunction.

Modern cochlear implants (CIs) use pulsatile stimulation to restore hearing for individuals with severe hearing loss. CIs provide robust speech recognition in quiet but poorly represent temporal fine structure (TFS), needed for challenging listening situations. Analog stimulation preserves the acoustic waveform and may better encode TFS, yet it has not been evaluated combined with modern current-focusing strategies. We compared neural responses in the inferior colliculus (IC) evoked by CI stimuli consisting of 100 pulses/s biphasic pulse trains and 100 cycles/s sinusoidal analog stimulation with monopolar, bipolar, and tripolar electrode configurations in urethane-anesthetized guinea pigs. Following cochlear implantation, multiunit activity was recorded from the tonotopic axis of the central nucleus of the IC using 16-channel silicon probes. Detection thresholds, spread of excitation, vector strength, sustained response percentage, and temporal response properties were quantified. Analog stimulation consistently evoked significantly lower activation thresholds than pulsatile stimulation while maintaining comparable or sometimes narrower spatial selectivity across stimulation modes. In contrast, analog stimulation generated lower vector strength, larger tonic response components, and a pronounced level-dependent polarity effect. At low stimulus levels, responses were dominated by the cathodic phase of the sinusoidal waveform, whereas increasing stimulus level responses were elicited by both phases, producing synchronization at twice the stimulus frequency. These findings demonstrate that stimulation waveform strongly influences temporal coding while having relatively little effect on the spatial distribution of neural activation. These results provide a physiological basis for reexamining analog stimulation as an alternative strategy for cochlear implant sound coding.