Cortical hyperexcitability to transcranial magnetic stimulation (TMS) is an early feature of amyotrophic lateral sclerosis (ALS) and it has been suggested that it might trigger motor neuron degeneration. Circuits of human motor cortex can be modulated non-invasively using repetitive transcranial magnetic stimulation (rTMS) and this technique has potential therapeutic effects in several neurological disorders including ALS. The effects of rTMS in ALS patients were evaluated in several small/ proof of principle studies. While some of the studies reported some benefit, another study reported that there was no significant difference between rTMS-treated and placebo-treated patients. The results of these studies were analyzed in a systematic Cochrane review that concluded that there is currently insufficient evidence to draw conclusions about the efficacy and safety of rTMS in the treatment of ALS and that further studies may be helpful to explore the potential benefit of brain stimulation in ALS. One of the main problems in the therapeutical use of rTMS is that the effects on cortical excitability are short lived making its potential limited. More prolonged effects on cortical excitability can be obtained by transcranial direct current stimulation (tDCS). Cathodal tDCS can suppress cortical excitability for several hours. In this proof of principle study, we evaluated the effects of cathodal tDCS on disease progression in two ALS patients.
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