Reviewer #3 (Public review):
Summary:
Borghi and colleagues present results from 4 experiments aimed at investigating the effects of dual γtACS and iTBS stimulation of the precuneus on behavioral and neural markers of memory formation. In their first experiment (n = 20), they found that a 3-minute offline (i.e., prior to task completion) stimulation that combines both techniques leads to superior memory recall performance in an associative memory task immediately after learning associations between pictures of faces, names, and occupation, as well as after a 15-minute delay, compared to iTBS alone (+ tACS sham) or no stimulation (sham for both iTBS and tACS). Performance in a second task probing short-term memory was unaffected by the stimulation condition. In a second experiment (n = 10), they show that these effects persist over 24 hours and up to a full week after initial stimulation. A third (n = 14) and fourth (n = 16) experiment were conducted to investigate the neural effects of the stimulation protocol. The authors report that, once again, only combined iTBS and γtACS increase gamma oscillatory activity and neural excitability (as measured by concurrent TMS-EEG) specific to the stimulated area at the precuneus compared to a control region, as well as precuneus-hippocampus functional connectivity (measured by resting-state MRI), which seemed to be associated with structural white matter integrity of the bilateral middle longitudinal fasciculus (measured by DTI).
Strengths:
Combining non-invasive brain stimulation techniques is a novel, potentially very powerful method to maximize the effects of these kinds of interventions that are usually well-tolerated and thus accepted by patients and healthy participants. It is also very impressive that the stimulation-induced improvements in memory performance resulted from a short (3 min) intervention protocol. If the effects reported here turn out to be as clinically meaningful and generalizable across populations as implied, this approach could represent a promising avenue for the treatment of impaired memory functions in many conditions.
Methodologically, this study is expertly done! I don't see any serious issues with the technical setup in any of the experiments (with the only caveat that I am not an expert in fMRI functional connectivity measures and DTI). It is also very commendable that the authors conceptually replicated the behavioral effects of experiment 1 in experiment 2 and then conducted two additional experiments to probe the neural mechanisms associated with these effects. This certainly increases the value of the study and the confidence in the results considerably.
The authors used a within-subject approach in their experiments, which increases statistical power and allows for stronger inferences about the tested effects. They are also used to individualize stimulation locations and intensities, which should further optimize the signal-to-noise ratio.
Weaknesses:
I want to state clearly that I think the strengths of this study far outweigh the concerns I have. I still list some points that I think should be clarified by the authors or taken into account by readers when interpreting the presented findings.
I think one of the major weaknesses of this study is the overall low sample size in all of the experiments (between n = 10 and n = 20). This is, as I mentioned when discussing the strengths of the study, partly mitigated by the within-subject design and individualized stimulation parameters. The authors mention that they performed a power analysis but this analysis seemed to be based on electrophysiological readouts similar to those obtained in experiment 3. It is thus unclear whether the other experiments were sufficiently powered to reliably detect the behavioral effects of interest. That being said, the authors do report significant effects, so they were per definition powered to find those. However, the effect sizes reported for their main findings are all relatively large and it is known that significant findings from small samples may represent inflated effect sizes, which may hamper the generalizability of the current results. Ideally, the authors would replicate their main findings in a larger sample. Alternatively, I think running a sensitivity analysis to estimate the smallest effect the authors could have detected with a power of 80% could be very informative for readers to contextualize the findings. At the very least, however, I think it would be necessary to address this point as a potential limitation in the discussion of the paper.
It seems that the statistical analysis approach differed slightly between studies. In experiment 1, the authors followed up significant effects of their ANOVAs by Bonferroni-adjusted post-hoc tests whereas it seems that in experiment 2, those post-hoc tests where "exploratory", which may suggest those were uncorrected. In experiment 3, the authors use one-tailed t-tests to follow up their ANOVAs. Given some of the reported p-values, these choices suggest that some of the comparisons might have failed to reach significance if properly corrected. This is not a critical issue per se, as the important test in all these cases is the initial ANOVA but non-significant (corrected) post-hoc tests might be another indicator of an underpowered experiment. My assumptions here might be wrong, but even then, I would ask the authors to be more transparent about the reasons for their choices or provide additional justification. Finally, the authors sometimes report exact p-values whereas other times they simply say p < .05. I would ask them to be consistent and recommend using exact p-values for every result where p >= .001.
While the authors went to great lengths trying to probe the neural changes likely associated with the memory improvement after stimulation, it is impossible from their data to causally relate the findings from experiments 3 and 4 to the behavioral effects in experiments 1 and 2. This is acknowledged by the authors and there are good methodological reasons for why TMS-EEG and fMRI had to be collected in sperate experiments, but it is still worth pointing out to readers that this limits inferences about how exactly dual iTBS and γtACS of the precuneus modulate learning and memory.
There were no stimulation-related performance differences in the short-term memory task used in experiments 1 and 2. The authors argue that this demonstrates that the intervention specifically targeted long-term associative memory formation. While this is certainly possible, the STM task was a spatial memory task, whereas the LTM task relied (primarily) on verbal material. It is thus also possible that the stimulation effects were specific to a stimulus domain instead of memory type. In other words, could it be possible that the stimulation might have affected STM performance if the task taxed verbal STM instead? This is of course impossible to know without an additional experiment, but the authors could mention this possibility when discussing their findings regarding the lack of change in the STM task.
While the authors discuss the potential neural mechanisms by which the combined stimulation conditions might have helped memory formation, the psychological processes are somewhat neglected. For example, do the authors think the stimulation primarily improves the encoding of new information or does it also improve consolidation processes? Interestingly, the beneficial effect of dual iTBS and γtACS on recall performance was very stable across all time points tested in experiments 1 and 2, as was the performance in the other conditions. Do the authors have any explanation as to why there seems to be no further forgetting of information over time in either condition when even at immediate recall, accuracy is below 50%? Further, participants started learning the associations of the FNAT immediately after the stimulation protocol was administered. What would happen if learning started with a delay? In other words, do the authors think there is an ideal time window post-stimulation in which memory formation is enhanced? If so, this might limit the usability of this procedure in real-life applications.