Transcranial magnetic stimulation (TMS) is an established technique in which a painless pulse of fast rising magnetic field is used to induce an electric current intracranially, causing depolarisation of nerve membranes and the generation of action potentials. It produces early motor responses trans-synaptically via the pyramidal tract. There are other effects, which are subject to changes in the GABAergic and monoaminergic systems and in sodium and calcium channel properties,1 the first of these showing particular relevance to human plasticity.2 In addition to the familiar clinical studies of central motor conduction time, TMS is used for single motor unit studies, mapping of the motor cortex, the determination of motor threshold or cortical excitability, intracortical inhibition and facilitation studies (using a paired pulse protocol, to express interneuronal connectivity involving the motor cortex), stimulus-response recruitment curves, sensory studies (including the production of phosphenes), and for the targeted disruption of motor or cognitive task performance. Triple stimulation protocols can provide quantitative data on central conduction failure and mapping studies with TMS can be coregistered with structural and functional MRI, or used for the study of functional connectivity across brain regions when combined with simultaneous PET.3 4

A combination of these approaches have now converged on several themes, including the study of excitability changes and plasticity after stroke. Transcranial magnetic stimulation has started to provide support for at least two models of reactive motor changes, in which adaptive reorganisation seems to involve cortical areas that may or may not have been implicated originally in the function of the infarcted area (vicariation and substitution, respectively). These models have stood the test of time but now require thorough re-examination, in parallel with recent elegant work in the monkey.5 The seeds of these two processes are identified within the studies reviewed briefly here, from …