Primary cervical dystonia and scoliosis: a multicenter case-control study

OBJECTIVE

To study the distribution of prior scoliosis among patients with primary adult-onset cervical dystonia (CD) and matched control subjects.

METHODS

Case and control subjects were selected among consecutive outpatients attending four Italian centers. Control outpatients were matched for age (+/-5 years), sex, and referral center. Information on prior scoliosis, other spine diseases, and family history of dystonia was obtained by a standardized questionnaire and supported by medical records. Conditional logistic regression models were used to adjust simultaneously for age, disease duration, and education level and to determine the independent association of exposure variables with the outcome.

RESULTS

Prior scoliosis developing in middle or late childhood or at around the puberty occurred more frequently among 72 case patients than among 144 neurologic control subjects. No subject reported conditions considered to be responsible for secondary scoliosis. The association of scoliosis and CD was not confounded by age, duration of disease, education level, other spine diseases, or family history of dystonia (adjusted odds ratio [OR] 6.8; 95% CI 1.5 to 29.5; p = 0.011). The OR of family history of dystonia (18.7; 95% CI 2.4 to 147.5; p = 0.005) fell to 11.7 (95% CI 1.3 to 103; p = 0.03) after controlling for scoliosis.

CONCLUSIONS

Prior scoliosis may increase the risk of developing CD. The observed decrease in the magnitude of the association between family history of dystonia and CD after controlling for scoliosis suggests a link between the two conditions.

Does sex influence age at onset in cranial-cervical and upper limb dystonia?

The relation between age at dystonia onset and sex was investigated in 264 patients with cranial-cervical dystonia and 56 patients with upper limb dystonia. In cranial-cervical dystonia, women had a significantly greater age at the onset of dystonia than men. The association was independent of duration of disease and distance of referral, but it was no longer detectable after adjustment for educational level. In upper limb dystonia, men and women did not differ for age at dystonia onset, duration of disease, education level, or distance of referral. A significant inverse association between age at the onset of dystonia and education was observed in both cranial-cervical dystonia and upper limb dystonia series.

Relaxation in distal and proximal arm muscles: a reaction time study

OBJECTIVE

To investigate whether the same mechanisms underlie muscle relaxation in proximal and distal arm muscles of normal subjects.

METHODS

Fourteen healthy subjects were studied using a simple visual reaction time paradigm. Relaxation reaction time (R-RT) and contraction reaction time (C-RT) were compared across different tasks involving distal (first dorsal interosseus, FDI, flexor carpi radialis, FCR) and proximal (biceps brachii, BB, triceps brachii, TR) arm muscles. Changes of FCR H-reflex before and during voluntary relaxation were investigated in two subjects.

RESULTS

No significant difference was observed between R-RT and C-RT in the distal muscles. The R-RT was significantly shorter than C-RT in both the BB and TR muscles. The relaxation latency (R-RT) was significantly correlated to the subjects' age in all the muscles except the FDI. No inhibition of the FCR H-reflex could be observed in the 20 ms preceding muscle relaxation.

CONCLUSIONS

Our findings suggest that neural mechanisms contribute differently to the relaxation of muscles with a different functional role. Voluntary relaxation in distal arm muscles is mainly related to the reduction of motor cortical output, while in proximal muscles a spinal disfacilitation is also present and possibly sustained by the modulation of presynaptic inhibition.

The medical management of spasticity

When spasticity produces a clinical disability by interfering with posture, motor capacity, nursing or daily living activities, medical treatment is recommended. It is mainly indicated when the muscle overactivity is diffusely distributed and should be implemented early, to prevent permanent musculoskeletal deformities or contractures. A pharmacological approach relies on the use of drugs which modulate neurotransmitters acting at the cortico-spinal level (GABA, glycine, glutamate, noradrenaline, serotonin). The aim of this treatment is to decrease spinal reflex excitability by reducing the release of excitatory neurotransmitters, or by potentiating the activity of inhibitory inputs. Evaluation of the efficacy of these drugs is determined by the therapeutic objectives which may be biomechanical, or functional. Diazepam increases presynaptic inhibition by stimulating GABA(A) receptors in the brainstem and spinal cord. In double-blind studies of patients with spinal cord lesions, antispastic efficacy has been shown, but side-effects are common. Baclofen stimulates GABA(B) receptors inducing a suppression of excitatory neurotransmitter release. Antispastic efficacy is sufficiently documented, but no definite effects on ambulation or activities of daily living have been proved. Tizanidine has an alpha2-agonist activity (at spinal and supraspinal level) and decreases the presynaptic activity of excitatory interneurones. The main clinical effects are a reduction in tonic stretch, polysynaptic reflexes, and co-contraction, with fewer side-effects but no definite functional change. The efficacy of several other antispastic drugs is documented in a few controlled studies, but the majority of information arises from open trials or anecdotal observations.

Differential modulation of motor evoked potential and silent period by activation of intracortical inhibitory circuits

OBJECTIVES

To investigate the effect of activation of intracortical inhibitory circuits, as tested by short interval (3 ms) paired-pulse transcranial magnetic stimulation (TMS) with a conditioning-test paradigm, on the electromyographic (EMG) pause (silent period, SP) following the motor evoked potential (MEP) in normal subjects.

METHODS

SPs and MEPs were recorded from the right first dorsal interosseous (FDI) muscle during a tonic voluntary contraction (from 70 to 90% of the maximum). Using a focal coil, we compared the SP duration after single-pulse TMS, paired-pulse TMS and single-pulse TMS of reduced intensity such as to evoke MEPs matched in size to the conditioned ones after paired-pulse TMS. In addition, we compared in a control experiment the duration of the SP following matched size MEPs evoked, respectively, by focal TMS with preferential activation of indirect I1- or I3-waves.

RESULTS

SP duration after paired-pulse TMS was significantly longer than after single-pulse TMS evoking MEPs of a similar size. In no case the SP duration was longer when focal TMS preferentially activated I1-waves.

CONCLUSIONS

The conditioning sub-threshold stimulus is more powerful in reducing the MEP size than in cutting down the subsequent EMG silence, suggesting that the neural circuits underlying MEP and SP are, at least in part, different.

No evidence of association between CAG expansions and essential tremor in a large cohort of Italian patients

Essential tremor (ET) is one of the most common movement disorders. However the pathogenesis is as yet unknown, although a genetic cause has long been recognised. Clinical and molecular evidences suggested that the ET gene might contain a CAG expanded region. In a cohort of Italian ET patients Repeat Expansion Detection (RED) approach did not demonstrate large CAG expansions. We extended the study towards specific targets: the channel proteins hSKCa3 and CACNL1A4. Direct assessment of CAG stretches within these two genes did not demonstrate any CAG expansion in affected subjects. Also a case-control analysis failed to reveal any evidence of association, thus excluding these genes as a cause of ET.

Tremor associated with benign IgM paraproteinaemic neuropathy successfully treated with gabapentin

We describe a 76-year-old patient with a severe tremor due to chronic demyelinating neuropathy associated with a benign IgM paraproteinaemia that was successfully treated with gabapentin. The patient reached the full dose of 1,200 mg/day of gabapentin without side effects and showed a significant therapy-related improvement of tremor and disability, as judged by the Fahn Tolosa Marin Rating Scale.

Abnormalities of sensorimotor integration in focal dystonia: a transcranial magnetic stimulation study

It has been postulated that sensorimotor integration is abnormal in dystonia. We investigated changes in motor cortical excitability induced by peripheral stimulation in patients with focal hand dystonia (12 patients with hand cramps) and with cervical dystonia (nine with spasmodic torticollis) compared with 16 age-matched normal controls. Motor evoked potentials (MEP) to focal (figure-of-eight coil) transcranial magnetic stimulation of the hand area were recorded from the right abductor pollicis brevis (APB), first dorsal interosseus (FDI), flexor carpi radialis and extensor carpi radialis muscles. Changes of test MEP size following conditioning stimulation of the right median nerve (or of the index finger) at conditioning-test (C-T) intervals of 50, 200, 600 and 1000 ms were analysed. Peripheral stimulation significantly reduced test MEP size in the APB and FDI muscles of normal control and spasmodic torticollis patients. The inhibitory effect was larger upon median nerve stimulation and reached a maximum at the C-T interval of 200 ms. On the contrary, hand cramp patients showed a significant facilitation of test MEP size. This study suggests that MEP suppression following peripheral stimulation is defective in patients with focal hand dystonia. Central processing of sensory input is abnormal in dystonia and may contribute to increased motor cortical excitability.

Clinical and genetic study of essential tremor in the Italian population

Essential tremor (ET) is one of the most common movement disorders. The pathogenesis is as yet unknown, although a genetic cause has long been recognised. Clinical and molecular evidence suggested that the ET gene contains a CAG expanded region. We examined a cohort of 240 Italian ET patients, classified as familial (193 cases) and sporadic (47 cases). The clinical manifestations of ET patients confirmed that the disorder is characterised by a large phenotypic variability. Repeat expansion detection (RED) approach did not demonstrate large CAG expansions. Six families were genotyped with 12 microsatellites markers of 2p and 3q regions and analysed according to parametrical methods. Lod scores values obtained in these families excluded the association of ET with 2p and 3q loci. Our findings confirm the presence of genetic heterogeneity and suggest that at least a third locus is involved in the pathogenesis of familial essential tremor.

Intracortical inhibitory circuits and sensory input: a study with transcranial magnetic stimulation in humans

We compared intracortical inhibition (ICI) following paired transcranial magnetic stimulation (TMS) (interstimulus interval, ISI: 3 ms) and the inhibition of motor evoked potentials (MEPs) to TMS induced by stimulation of the median nerve (ISI: 200 ms) in six normal subjects. MEPs evoked by focal TMS were recorded in the relaxed opponens pollicis muscle and the size of the conditioned responses was expressed as a percentage of the size of the non-conditioned responses. Maximal ICI, ranging from 4 to 40%, and inhibition after median nerve stimulation, ranging from 11 to 68%, were significantly correlated. The results suggest that both phenomena are possibly mediated by the same gamma aminobutyric acid-ergic (GABAergic) inhibitory circuits and that afferent inputs to the cortex may contribute to their physiological activation.

Abnormalities of motor cortical excitability are not correlated with clinical features in atypical parkinsonism

OBJECTIVE

To evaluate the specificity of motor cortical excitability changes in parkinsonian syndromes and their relevance to the pathophysiology of cardinal parkinsonian features.

METHODS

Paired transcranial magnetic stimulation (TMS) was used to assess cortico-cortical inhibition (CCI) and facilitation (CCF) in the opponens pollicis muscle of patients with atypical, non-L-dopa- (LD) responsive parkinsonism.

RESULTS

Compared with age-matched normal control subjects, CCI (interstimulus interval [ISI], 3 ms) was significantly reduced in 10 patients with predominantly parkinsonian multiple system atrophy (MSA-P) and in seven with vascular parkinsonism (VP), but not in four with predominantly cerebellar MSA. No significant change of CCF (ISI, 12 ms) was observed. No correlation was found between the amount of CCI and clinical status as evaluated with the Unified Parkinson's Disease Rating Scale (UPDRS). In 10 patients (5 MSA-P, 5 VP), CCI was significantly increased by LD acute administration without concurrent clinical changes.

CONCLUSIONS

Abnormalities of CCI are not peculiar to idiopathic Parkinson's disease and seem unlikely to underlie any specific parkinsonian feature, but rather possibly reflect a nonspecific imbalance of inhibitory and facilitatory motor cortical circuits.

Motor recovery following stroke: a transcranial magnetic stimulation study

OBJECTIVES

To verify the usefulness of early recording of motor evoked potentials (MEPs) in predicting motor outcome after stroke and to investigate the neural mechanisms underlying functional recovery following stroke.

METHODS

We performed a comparative analysis of the behaviour of motor responses evoked by transcranial magnetic stimulation (TMS) of the ipsilateral and contralateral motor cortex in the affected and unaffected thenar muscles of 21 consecutive patients with acute stroke.

RESULTS

According to the behaviour of MEPs in the affected muscles, patients could be divided into 3 groups: (a) 10 subjects with absent responses to TMS of both the damaged and undamaged hemisphere, whose motor recovery was poor and related to the size of MEPs on the normal side; (b) 5 subjects with larger MEPs upon TMS of the ipsilateral (undamaged) than of the contralateral (damaged) cortex, whose good recovery possibly resulted from the emergence of ipsilateral pathways; (c) 6 subjects with larger MEPs in the affected than in the unaffected muscles, whose good recovery was possibly subserved by alternative circuits taking over cortical deafferentation.

CONCLUSIONS

Early MEP recording in acute stroke provides useful information on the clinical prognosis and the different mechanisms of motor recovery.

The role of sensory cues in the rehabilitation of parkinsonian patients: a comparison of two physical therapy protocols

We devised a single-blind study to assess the role of providing external sensory cues in the rehabilitation of patients with idiopathic Parkinson's disease (PD). Twenty stable, nondemented patients with PD entered a 6-week rehabilitation program and were randomly assigned to two balanced protocols which were differentiated by the use of external sensory cues ("non-cued" vs "cued"). Patients were evaluated by a neurologist, who was blind to group membership, with the Unified Parkinson's Disease Rating Scale (UPDRS) at baseline, end of treatment, and after 6 weeks. Patient groups were comparable for age, disease duration, and severity. A significant reduction of UPDRS scores (activities of daily living and motor sections) was present after the rehabilitation phase in both groups. However, at follow up, while this clinical improvement had largely faded in the "non-cued" group, mean UPDRS scores of the "cued" group were still significantly lower than baseline values. The incorporation of external sensory cues in the rehabilitation protocol can extend the short-term benefit of physical therapy in moderately disabled patients with PD, possibly as a result of the learning of new motor strategies. "Cued" physical therapy for PD should be targeted to compensate for the defective physiological mechanisms.

Full length alpha-synuclein is present in cerebrospinal fluid from Parkinson's disease and normal subjects

Several clues suggest that alpha-synuclein, a presynaptic protein, plays a central role in the pathogenesis of idiopathic Parkinson's disease (PD). To search a peripheral marker of PD, we analyzed presence and amount of alpha-synuclein in CSF from 12 PD patients and 10 neurologically normal subjects. The protein was extracted from CSF samples through immunoprecipitation and immunoblotting with different specific anti-alpha-synuclein antibodies. We identified a 19 kDa band that corresponds to monomeric alpha-synuclein, given its comigration with homologue human recombinant peptide as well as with the protein extracted from cerebral cortex of normal subjects. The amount of CSF 19 kDa alpha-synuclein did not significantly vary in PD and normal cases. These findings have two implications: (a) full length alpha-synuclein is released by neurons in the extracellular space; (b) alpha-synuclein does not appear a peripheral marker of PD pathology.

Primary hemifacial spasm and arterial hypertension: a multicenter case-control study

In a case-control study, the authors found that arterial hypertension occurred more frequently among 115 patients with primary hemifacial spasm than among 115 neurologic controls matched for age (+/-5 years), sex, and referral center. The association was not confounded by education level, smoking history, diabetes, or other diseases (adjusted OR 2.64; 95% CI 1.3 to 5.33, p = 0.007). Hypertension was significantly associated with the outcome in the left-sided group (OR 4.0; 95% CI 1.4 to 11.5), but data concerning patients with right-sided spasm were inconclusive (OR 1.05; 95% CI 0.36 to 3.1). In our sample, hypertension either preceded or followed the onset of hemifacial spasm.

Corticobasal degeneration shares a common genetic background with progressive supranuclear palsy

Corticobasal degeneration is a sporadic form of tauopathy, involving the cerebral cortex and extrapyramidal motor system. A series of affected subjects was genotyped for a set of genetic markers along the tau protein gene. A specific haplotype is significantly overrepresented in patients versus controls. This haplotype is the same already reported in association with progressive supranuclear palsy. These data show that corticobasal degeneration and progressive supranuclear palsy, in addition to several clinical, pathological, and molecular features, may have the same genetic background.

Risk factors for spread of primary adult onset blepharospasm: a multicentre investigation of the Italian movement disorders study group

OBJECTIVES

Little is known about factors influencing the spread of blepharospasm to other body parts. An investigation was carried out to deterrmine whether demographic features (sex, age at blepharospasm onset), putative risk, or protective factors for blepharospasm (family history of dystonia or tremor, previous head or face trauma with loss of consciousness, ocular diseases, and cigarette smoking), age related diseases (diabetes, hypertension), edentulousness, and neck or trunk trauma preceding the onset of blepharospasm could distinguish patients with blepharospasm who had spread of dystonia from those who did not.

METHODS

159 outpatients presenting initially with blepharospasm were selected in 16 Italian Institutions. There were 104 patients with focal blepharospasm (mean duration of disease 5.3 (SD 1.9) years) and 55 patients in whom segmental or multifocal dystonia developed (mainly in the cranial cervical area) 1.5 (1.2) years after the onset of blepharospasm. Information was obtained from a standardised questionnaire administered by medical interviewers. A Cox regression model was used to examine the relation between the investigated variables and spread.

RESULTS

Previous head or face trauma with loss of consciousness, age at the onset of blepharospasm, and female sex were independently associated with an increased risk of spread. A significant association was not found between spread of dystonia and previous ocular diseases, hypertension, diabetes, neck or trunk trauma, edentulousness, cigarette smoking, and family history of dystonia or tremor. An unsatisfactory study power negatively influenced the validity and accuracy of the negative findings relative to diabetes, neck or trunk trauma, and cigarette smoking.

CONCLUSIONS

The results of this exploratory study confirm that patients presenting initially with blepharospasm are most likely to experience some spread of dystonia within a few years of the onset of blepharospasm and suggest that head or face trauma with loss of consciousness preceding the onset, age at onset, and female sex may be relevant to spread. The suggested association between edentulousness and cranial cervical dystonia may be apparent because of the confounding effect of both age at onset and head or face trauma with loss of consciousness. The lack of influence of family history of dystonia on spread is consistent with previous findings indicating that the inheritance pattern is the same for focal and segmental blepharospasm.

Intracortical inhibition after paired transcranial magnetic stimulation depends on the current flow direction

OBJECTIVES

To assess whether cortico-cortical inhibition (CCI) induced by paired-pulse transcranial magnetic stimulation (TMS) is influenced by 'preferential' or 'non-preferential' activation of the motor cortex.

METHODS

Paired-pulse TMS (conditioning-test paradigm with interstimulus intervals of 2-5 ms) with a round coil centered over the vertex was performed in 10 normal subjects using opposite current flow directions. The amount of CCI in the opponens pollicis and first dorsal interosseus muscles was determined.

RESULTS

When a clockwise current was induced in the brain (side A of the coil uppermost) a 'preferential' activation of the left hemisphere (right hand muscles) was observed, but the suppression of the test response by the conditioning stimulus (i.e. the CCI) was significantly greater in the left hand muscles. The situation was reversed when an anticlockwise current (side B of the coil uppermost) was induced in the brain. These effects occurred independently of the interstimulus interval, or of the absolute conditioning stimulus strength.

CONCLUSIONS

CCI is more effective in the 'non-preferentially' stimulated hemisphere, and the neural elements generating the indirect I3 wave are more sensitive to intracortical inhibition than those generating the I1 wave.

Changes of intracortical inhibition during motor imagery in human subjects

Paired-pulse transcranial magnetic stimulation with a conditioning-test paradigm was used to assess changes of corticocortical inhibition and facilitation during mental simulation of sequential finger movements in normal subjects. The cortico-cortical inhibition (at interstimulus interval, ISI, of 3 ms) was significantly reduced in the relaxed opponens pollicis (OP) muscle during motor imagery, regardless of the absolute size of the test motor evoked potential. The amount of cortico-cortical inhibition was similar to that observed during a mild voluntary contraction of the OP. No change of cortico-cortical facilitation was observed at the ISI of 12 ms. The data support the hypothesis that similar neural structures, including the primary motor cortex, are activated during both mental simulation and actual execution of motor activities.

Comparison of intracortical inhibition and facilitation in distal and proximal arm muscles in humans

1. Cortico-cortical inhibition and facilitation induced by paired transcranial magnetic stimulation (TMS) of the human motor cortex were investigated in the distal muscle opponens pollicis (OP) and the proximal muscle biceps brachii (BB) of normal subjects. 2. The test response evoked by TMS (125 % of motor threshold, MTh) in the relaxed OP and BB muscles was inhibited by a conditioning TMS (80 % of MTh) at short interstimulus intervals (ISIs; 2-5 ms) and facilitated at longer ISIs (10-25 ms). The test response was significantly less inhibited at short ISIs and more facilitated at long ISIs in the BB than OP. 3. The MTh at rest was significantly lower for the OP than for the BB, indicating a greater excitability of OP cortical area. However, the above pattern of inhibition and facilitation was preserved both when the stimulus intensity was adjusted to evoke test responses of matched size in the two muscles and within an ample range of conditioning stimulus intensities. 4. The use of a circular coil or a focal figure-of-eight coil produced no qualitative differences in the pattern of inhibition and facilitation in either muscle. 5. The significant difference in MTh between muscles was lost during voluntary activation. In both muscles, pre-innervation abolished the cortico-cortical facilitation and reduced the cortico-cortical inhibition. However, the latter remained larger in the OP than BB muscle. 6. We suggest that the different potency of intracortical inhibitory and facilitatory circuits directed towards distal and proximal arm muscles is related to their diverse prevalent functions.

Responses of masseter muscles to transcranial magnetic stimulation in patients with amyotrophic lateral sclerosis

We recorded motor responses evoked by transcranial magnetic stimulation (TMS) in the masseter muscles of 30 patients with amyotrophic lateral sclerosis (ALS), 10 patients with cervical spondylotic myelopathy (CSM) and 22 age-matched normal controls. Responses to direct activation of the trigeminal motor root (R-MEPs) were normal both in ALS and CSM patients. Responses to activation of cortico-bulbar descending fibers (C-MEPs) were absent or delayed in 19 ALS patients (63.3%). Abnormalities of masseter C-MEPs were more frequent than abnormalities of limb MEPs and could be observed both in patients with (77.8%) and without (41.7%) clinical bulbar signs. Masseter C-MEPs were normal in all CSM patients. Recording masseter responses to TMS can reveal the frequent impairment of cortico-bulbar projections in ALS and can be useful in the differential diagnosis of spinal cord compression disorders mimicking ALS because of combination of upper and lower motor neuron signs.

Predictive testing for Huntington's disease: ten years' experience in two Italian centres

Pre-symptomatic testing for Huntington's disease (HD) has been available as a clinical service in the medical centres of Rome and Genoa since December 1987, initially by DNA-linkage and since mid-1993 by direct mutation analysis. A multidisciplinary approach and a protocol which follows the Ethical Issue Policy Statement on Huntington's Disease Molecular Genetics Predictive Test has been used. In the period under study, 332 subjects requested the test, 288 were enrolled in the protocol and nearly half of these completed it. One hundred and forty-eight people withdrew from the testing procedure for various reasons but most frequently due to a more realistic evaluation of all possible consequences of test results, induced by psychological counselling. Therefore, 140 people completed the test. The overall gene-carrier/non-carrier ratio was 0.46:1. None of the identified gene carriers had catastrophic reactions such as suicide, suicide attempts or major psychiatric disorders. All appear to have had a similar pattern of reactions to an adverse result and none expressed regret for undergoing the test. In conclusion, presymptomatic testing for HD can be considered a safe procedure without adverse consequences when framed in an integrated protocol at qualified genetic centres.

Possible risk factors for primary adult onset dystonia: a case-control investigation by the Italian Movement Disorders Study Group

OBJECTIVES

Little is known about the aetiology of idiopathic adult onset dystonia. The Italian Movement Disorders Study Group promoted a case-control study on some hypothetical risk factors including past medical events, life events, life habits, occupational hazards, and family history of dystonia, parkinsonism, and tremor.

METHODS

Cases affected by idiopathic adult onset dystonia (age at symptom onset >20 years, duration of disease >one year and <five years) were selected among consecutive outpatients attending 14 Italian centres. Control outpatients matched for age (+/-5 years), sex, and referral centre were identified among diagnostic categories thought to be unassociated with study exposures. Information was obtained by a standardised questionnaire administered by medical interviewers. Conditional logistic univariate and multivariate regression analyses were performed by a standard statistical package.

RESULTS

Multivariate analysis on 202 cases and 202 age and sex matched control outpatients indicated that head or facial trauma with loss of consciousness, family history of dystonia, and family history of postural tremor independently increased the risk of developing adult onset dystonia, whereas hypertension and cigarette smoking exerted a protective effect. The findings also suggested a positive association between local body injury-for example, previous ocular diseases and neck or trunk trauma-and dystonia of the same body part.

CONCLUSIONS

The results support the idea that environmental and genetic factors may both be important in the aetiology of adult onset dystonia, and suggest aetiological clues worthy of further analytical investigation.

Guidelines for the therapeutic use of botulinum toxin in movement disorders. Italian Study Group for Movement Disorders, Italian Society of Neurology

Since its introduction in the early '80s the use of botulinum toxin has improved the quality of life of the patients affected by movement disorders. Toxin's neuromuscular blocking action allows a symptomatic treatment of those clinical conditions characterised by excessive muscular activity. Although the dosages used are safe and the side-effects are reversible, a correct use of botulinum toxin depends on the knowledge of its clinical pharmacology and of the anatomy of the body segments to be injected. In addition, the treatment of more complex conditions, i.e. laringeal dystonia, imposes an inter-disciplinary approach and specialised injection techniques. In this review, the Italian Study Group on Movement Disorders presents the consensus guidelines for the therapeutic use of botulinum toxin in movement disorders. The main toxin types, their use and administration modalities, and the training guidelines will be presented.

Intracortical inhibition and facilitation are abnormal in Huntington's disease: a paired magnetic stimulation study

Transcranial magnetic stimulation with a conditioning-test paradigm was used to assess cortico-cortical interactions in the motor cortex of 11 patients with Huntington's disease (HD) as compared to normal controls (NC). In the HD patients, threshold and amplitude of motor potentials evoked in the opponens pollicis muscle at rest were not significantly different from NC. The cortico-cortical inhibition at interstimulus intervals of 2-5 ms was significantly reduced and the cortico-cortical facilitation at longer intervals (10-25 ms) was significantly enhanced. Changes of intracortical inhibition and facilitation were related to clinical rating of choreic dyskinesias. The data support the hypothesis of a functional impairment of the motor cortex-basal ganglia loop in HD patients.

Sensory and motor evoked potentials in multiple system atrophy: a comparative study with Parkinson's disease

Somatosensory evoked potentials (SEPs) to median nerve stimulation and motor evoked potentials to transcranial magnetic stimulation (TMS) of the motor cortex were studied in 15 patients with multiple system atrophy (MSA) and compared with matched groups of 20 patients with idiopathic Parkinson's disease (PD) and of 20 normal controls (NCs). No SEP latency or amplitude abnormalities were observed, and, in particular, the frontal N30 component was not significantly depressed. No differences in TMS threshold for evoking responses in relaxed or active thenar muscles were observed. The mean central motor conduction time was normal for the biceps brachii and opponens pollicis muscles and prolonged in the MSA group for the tibialis anterior muscle. Recording SEPs is not useful to differentiate MSA from PD, while the presence of central motor conduction abnormalities may bring into question the diagnosis of idiopathic PD.

The excitability of the human motor cortex increases during execution and mental imagination of sequential but not repetitive finger movements

Motor potentials (MEPs) evoked by focal (figure-of-eight coil) transcranial magnetic stimulation of the left motor cortex were recorded from the right opponens pollicis (OP) and flexor digitorum superficialis (FDS) of 14 normal subjects during different motor tasks. Changes in motor cortical excitability under behavioural conditions presumably connected with premotor and supplementary motor area (SMA) activation were investigated by comparing the size of the MEPs obtained during: (1) rest, (2) mental calculus, (3) repetitive left thumb-to-index opposition, (4) mental simulation of the same task with the right hand, (5) sequences of left thumb-to-fingers opposition, and (6) mental simulation of the same sequences with the right hand. MEP size significantly increased in both muscles during sequential movements of the left hand and sequence simulation with the right hand, but not during mental calculus or actual or simulated repetitive movements. The H-reflex evoked in the OP and FDS muscles by electrical stimulation of the median nerve (at wrist and elbow, respectively) under the same experimental conditions did not show significant modifications. The increase in MEP size during non-routine actual or imagined sequences of finger movements supports the view that the SMA is activated under these conditions and that it exerts a direct facilitatory influence on the motor cortex.

Selective facilitation of responses to cortical stimulation of proximal and distal arm muscles by precision tasks in man

1. The responses of the first dorsal interosseus (1DI), opponens pollicis (OP), extensor digitorum communis (EDC), brachioradialis (BR), biceps brachii (BB) and anterior deltoid (AD) muscles to magnetic stimulation of the motor cortex were recorded during different motor tasks. 2. Two precision and two power isometric tasks were investigated. The precision tasks were a pincer grip ('grip') and a thrust against a target with the wrist ('push'). In the former, the prime movers were the intrinsic hand muscles, while the proximal muscles played a postural role. In the latter, the prime movers were the proximal muscles. In both tasks, force was controlled through visual feedback. The power tasks required encirclement of a cylinder with the fingers ('grasp'), or sustaining a weight suspended at wrist level ('load'). 3. Magnetic stimulation was applied in eight subjects by a coil placed over the vertex at 1.1-1.2 times the motor threshold for the most excitable muscles. This produced in the prime mover muscles larger motor-evoked responses (MEPs) during grip or push tasks than grasp or load tasks, in spite of similar background EMG levels. During grip tasks, only one of the two prime movers showed task-dependent changes. In the postural muscle AD there was no significant difference between MEPs during grip and grasp tasks; however, BB responses were larger during grasp than grip tasks. 4. MEPs simultaneously recorded in the prime movers were plotted against each other. The slope of the regression line for AD versus BB was larger in push than load tasks, whilst the changes in MEPs of 1DI and OP were independent during both grip and grasp tasks. 5. In three subjects, MEPs were also elicited by electrical stimulation during grip and grasp tasks. MEP changes tended to parallel those obtained for magnetic stimulation, but the increase in size of the electrically evoked MEPs during the precision task was smaller. 6. In all subjects the median and ulnar nerves were stimulated during grip and grasp tasks, and an H reflex was evoked in the hand muscles of five subjects. In no case did the two tasks produce reflexes of different amplitude. 7. The motor response of both proximal and distal muscles can be task dependent, in spite of the differences in their principal functional role and cortical representation. The modulation is related to the degree of control requested by the task, and is likely to reflect selective changes in the excitability of corticospinal neurones.

Molecular analysis of the IT15 gene in patients with apparently 'sporadic' Huntington's disease

The diagnosis of Huntington's disease (HD) may be uncertain in patients without a positive family history, particularly when atypical clinical features are present. We examined the expanded trinucleotide (CAG) repeat sequence in the IT15 gene of 27 'sporadic' cases, classified as having clinically probable or clinically doubtful HD. An abnormal number of CAG repeats (42-85) were found in 14 patients. Mutation analysis confirmed the diagnosis in 63.6% of patients with clinically probable HD and in 43.7% of patients with clinically doubtful HD. DNA analysis allows an accurate diagnosis of apparently 'sporadic' HD patients and has important implications for genetic counselling.

Lowering body temperature with a cooling suit as symptomatic treatment for thermosensitive multiple sclerosis patients

A cooling system (Mark VII Microclimate System) was used to give six thermosensitive multiple sclerosis patients two 45-minute daily coolings for a period of one month. Before the first cooling, a baseline clinical and electrophysiological examination was performed. The same tests were repeated after the first application and after the thirtieth cooling day, thus providing information relating to acute and chronic efficacy. A clinical improvement was observed after both acute and, more unexpectedly, chronic cooling, whereas a significant improvement in central somatosensory conduction was recorded only under acute conditions. Our data suggest that cooling with this device leads to an improvement in some functional performances (mainly fatigue and strength) of about two hours' duration in thermosensitive patients.

Response of arm flexor muscles to magnetic and electrical brain stimulation during shortening and lengthening tasks in man

1. The responses of the brachioradialis and biceps brachii muscles to non-invasive magnetic and electrical stimulation of the human motor cortex have been investigated during performance of different tasks. 2. Both muscles were simultaneously active during elbow flexor isometric torque, or forearm flexion lifting a weight (shortening contraction), or extension breaking the fall of the weight (lengthening contraction). The forearm extensor triceps brachii muscle was not engaged in any task. By using different weights, comparable levels of EMG activity were obtained in the same muscle across tasks. 3. Both magnetic (7 subjects) and electrical (3 subjects) brain stimulation (at about 1.5 times the motor threshold) produced larger responses during shortening, and smaller responses during lengthening, in the brachioradialis muscle with respect to isometric contractions, in spite of equal background EMG levels. Responses evoked in the biceps brachii by either stimulation mode were smaller during lengthening but not significantly enhanced during shortening. No consistent differences in the task-related modulation of the responses were present between electrical or magnetic stimulations. No significant changes in the evoked responses occurred during passive elbow flexion or extension. 4. In three subjects, the H reflex was evoked in the brachioradialis by stimulation of the radial nerve during performance of the same tasks. The pattern of task-related modulation of the reflex amplitude paralleled that obtained for brain stimulation. 5. The opposite modulation induced by the shortening and lengthening tasks both in magnetically and electrically evoked motor responses, and in the H reflex, suggests that task-related changes in excitability of the cortical neurones play a minor role.(ABSTRACT TRUNCATED AT 250 WORDS)

Reliability among neurologists in the severity assessment of blepharospasm and oromandibular dystonia: a multicenter study

The reliability of a scale of 0 to 4 (where 0 is normal) in rating the severity of blepharospasm (BS) and oromandibular dystonia (OMD) was evaluated by the concordance among six neurologists from different neurological institutions. As expressed by k index, interobserver agreement was moderate either for BS or for OMD according to the Landis classification. Neurologists showed different rating attitude toward BS and OMD. In fact, the category analysis showed that raters were inclined to overestimate BS and to underestimate OMD. The familiarity with dystonia influenced reliability more than the length of professional experience in neurology. In fact, when examiners were subdivided into subgroups (each of three raters) according to the former criteria, the level of interobserver agreement increased significantly. Almost perfect agreement was obtained in intrarater comparisons. These results may be of value with regard to the conduct of multicenter epidemiologic and clinical studies on focal dystonias.

Motor evoked potentials following cervical electrical stimulation in brachial plexus lesions

The diagnostic relevance of recording motor evoked potentials (MEPs) after electrical stimulation of the cervical region, as compared with conventional needle electromyography (EMG), was evaluated in 26 patients with brachial plexus (BP) damage of different aetiology, severity and topography. MEP abnormalities (absence or latency increase) were observed in at least one muscle of all the patients, with a global incidence of 61.5% of the muscles examined. Neurogenic EMG signs were present in all but one patient with an incidence of 62.2% of the muscles examined. Combining the two methods, the global incidence of abnormalities rose to 69.9%. MEP abnormalities were consistent with the clinical topography and severity of BP lesions and were fairly parallel with EMG findings. Recording MEPs after percutaneous electrical stimulation of the cervical region may be regarded as a rapid, non-invasive method for quantitative electrophysiological assessment of BP damage.

Impairment of central motor conduction in diabetic patients

In 70 patients with diabetes mellitus (DM) we recorded the motor evoked potentials (MEPs) following magnetic stimulation of the motor cortex and spinal roots. Central motor conduction time (CMCT) was determined as the difference between MEP latencies after cortical and spinal stimulation. The mean CMCTs for the biceps, thenar and tibialis anterior muscles were prolonged in the DM group, as compared to normal controls, and 21 patients exceeded the CMCT upper confidence limit for at least one muscle. CMCT changes and peripheral conduction velocity abnormalities occurred independently and were related to different clinical parameters. We conclude that a subclinical impairment of central motor conduction is present in 30% of DM patients, independently from the occurrence of a diabetic peripheral neuropathy and possibly reflecting different pathophysiological mechanisms.

Botulinum toxin treatment in patients with focal dystonia and hemifacial spasm. A multicenter study of the Italian Movement Disorder Group

In six Centers belonging to the Italian Movement Disorder Study Group, the efficacy of botulinum toxin treatment was evaluated in an open collaborative study in 251 patients with focal dystonia and hemifacial spasm. The percentage of functional improvement ranged from 66% to 81% in patients with blepharospasm, from 40% to 51% in patients with spasmodic torticollis and from 73% to 81% in those with hemifacial spasm. Good results were also obtained in patients with oromandibular dystonia, laryngeal dystonia and writer's cramp. Side effects were mild and transient. Local botulinum toxin injection is the first choice symptomatic treatment in focal dystonia and hemifacial spasm.

Motor evoked potentials (MEPs) in lacunar syndromes

Motor evoked potentials (MEPs) evoked in the biceps, thenar and tibialis anterior muscles by electrical stimulation of the scalp and of the spinal regions were recorded in 32 patients with focal deficits due to minor cerebral ischemia of the lacunar type and in a control group. Somatosensory evoked potentials (SEPs) to median nerve stimulation were also recorded. The central motor conduction times (CMCTs) and the threshold intensities for eliciting MEPs in the relaxed muscles were significantly increased on the affected side. Central motor conduction, for at least one muscle, was altered in 18 patients. MEP abnormalities were related to pyramidal signs (though they could be observed also in a patient without any motor impairment) and occurred independently of a specific clinical picture or a radiologically confirmed lacunar lesion. SEPs were less frequently altered than MEPs.

Genetic analysis of Huntington disease in Italy

Twelve Italian families with Huntington disease were tested with 10 probes known to be linked to the disease locus and able to detect polymorphisms at the following loci on chromosome 4: D4S10, D4S127, D4S95, D4S43, D4S115, D4S111, D4S90. The results confirmed the applicability of the linkage approach for presymptomatic diagnosis in Italian families. Positive lod scores were found between D4S10, D4S95, D4S43 and the disease, whereas D4S90 did not indicate significant linkage values. With the limitations due to the small size of the tested sample, no genetic heterogeneity was detected in the families examined for loci D4S10, D4S95/S127, D4S43.

Motor and sensory evoked potentials in progressive supranuclear palsy

Motor potentials evoked in the biceps, thenar, and tibialis anterior muscles by electrical stimulation of the scalp and of the spinal regions were recorded in 12 patients with progressive supranuclear palsy (PSP) and in a control group. Abnormalities of central motor conduction for at least one muscle were present in five patients (41.7%), characterized by a long illness duration. The central sensory conduction time of the median nerve was normal, but five patients showed a depressed frontal N30 wave. These findings support the possible occurrence of functional damage to the corticospinal tracts and to the supplementary motor area in PSP.

Abnormalities of parietal and prerolandic somatosensory evoked potentials in Huntington's disease

Cervical, parietal and prerolandic somatosensory evoked potentials (SEPs) to median nerve stimulation at the wrist were recorded with an earlobe reference in 24 patients with Huntington's disease (HD) and in 24 age-matched normal controls. Cortical responses of abnormal wave form and reduced amplitude were constantly observed in HD patients. SEP changes affected more severely the prerolandic (P22/N30) pattern, which could not be recognized in two-thirds of patients, than the parietal (N20/P27) pattern, which could be identified in all cases. The N20 latency and the central conduction time (N13-N20 interval) were significantly increased. The occurrence of abnormalities of central conduction and of a predominant involvement of the prerolandic SEP pattern suggests an impairment of impulse transmission along the somatosensory lemniscal pathway at subcortical, possibly thalamic, level in HD.

Generalized dystonia with bilateral striatal computed-tomographic lucencies in a patient with human immunodeficiency virus infection

We report the case of a 36-year-old, drug-addicted woman with laboratory evidence of human immunodeficiency virus infection in the central nervous system. The patient presented with generalized dystonia involving both axial and segmental muscles, mainly in the legs, and with minimal additional neurological abnormalities. A computed-tomographic scan revealed bilateral and symmetrical lucencies in the putaminal region. The possibility of an acquired immunodeficiency syndrome-related manifestation is discussed.

Impaired habituation of long-latency stretch reflexes of the wrist muscles in Huntington's disease

Electromyographic responses to sudden wrist extension were recorded from the forearm and finger flexor muscles in 10 patients with Huntington's disease (HD) and in 10 normal controls. Stretch reflexes were characterized by a short-latency (SL) and a long-latency (LL) component both in patients and controls. Latency, duration, and size of the SL component were not different in the two groups, whereas the LL component was delayed in latency and reduced in size in HD patients. Increasing the stretch repetition rate from 0.1 to 0.4 cycles/s did not affect the SL component of either group, whereas the LL stretch reflex was reduced in size and duration in normal controls, but not in HD patients. These findings suggest an impairment of the "gain" mechanisms of the sole LL component, responsible for a desaturation of this component. This study supports the hypothesis that LL stretch reflexes are mediated by a transcortical long loop, possibly damaged in HD.

Selective effects of repetition rate on frontal and parietal somatosensory evoked potentials (SEPs)

The effects of changing the stimulus presentation rate on early parietal (N20-P25) and frontal (P22-N30) somatosensory potentials (SEPs), evoked by median nerve stimulation, were investigated in 15 normal subjects. Stimuli were presented at 0.1, 0.4, 1.0, 4.0 and 10/sec. Only minor latency changes, mainly for the frontal P22 component, were observed when the stimulus rate was increased up to 10/sec: while the frontal P22-N30 complex was more rapidly and severely reduced in amplitude than the parietal N20-P25 complex. The differential effects of stimulus presentation rate on early frontal and parietal SEPs support the hypothesis of separate neural generators and suggest that the choice of the stimulation frequency may be critical for the interpretation of diagnostic SEP studies.

Somatosensory-evoked potentials in the diagnosis of lacunar syndromes: comparison with EEG findings

Somatosensory-evoked potentials (SEPs) and EEG were recorded in 45 patients with lacunar syndrome due to CT-verified lacunar infarcts. Abnormalities of SEP chronological parameters were observed in 22 subjects. SEP changes occurred independently of clinical features and were related more to the lesion location than to its size.

Do muscle afferents contribute to the cervical response evoked by electrical stimulation of the median nerve in man?

The possible contribution of low threshold muscle afferents to the postsynaptic component (N13) of the cervical response evoked by electrical stimulation of the median nerve (MN) was investigated in normal subjects. Electroneurographic (ENG) and electromyographic (EMG) correlates of the reflex motoneuronal discharge (RMND) were recorded simultaneously. A. No reflex activity could be elicited by stimulation of the MN at the wrist, at least in the resting subjects, while well developed ENG (P2 efferent volley) and EMG (H reflex) monosynaptic responses occurred following stimulation of the MN at the elbow at suitable strengths. In neither case could a surface correlate of interneuronal activity evoked by muscle afferents be demonstrated. B. Recruitment curves showed that at stimulus intensities above maximal for the H reflex both P2 and H responses started to decrease until they completely disappeared, while N13 showed further enhancement. C. Subthreshold conditioning stimulation of the MN enhanced both P2 and H responses, while vibratory muscle stimuli provoked a clearcut suppression of these two responses. In contrast, N13 was completely unaffected by either manoeuvre. D. No cervical evoked activity could be detected following tendon tapping of the anterior forearm muscles in spite of the appearance of well developed cortical responses and the ENG and EMG correlates of the T reflex. E. Conditioning volleys elicited by tendon taps of the anterior forearm muscles suppressed both P2 and H responses following stimulation of the MN at the elbow without affecting the related N13 component. Conditioning supramaximal stimulation of the MN at the wrist suppressed the N13 component of the cervical response evoked by stimulation of the MN at the elbow without affecting the related reflex responses. No component chronologically related to the RMND could be recorded at the posterior neck region during suppression of N13, thus ruling out the possibility that failure to detect the RMND (as well as its interneuronal concomitants) with cervical electrodes is due to a masking effect of the N13 component. G. Conditioning tendon taps of anterior forearm muscles provoked a clearcut reduction of the primary cortical response to finger stimulation without affecting the postsynaptic component of the related cervical response. It is concluded that neither segmental (motoneuronal or interneuronal in origin) nor ascending postsynaptic impulses generated in the spinal cord by stimulation of low threshold muscle afferents contribute to N13, the latter being probably due to activation of both short and long axoned spinal neurons by cutaneous afferents.

Electrical stimulation of the motor tracts in cervical spondylosis

Motor action potentials evoked by percutaneous electrical stimulation of the scalp and of the cervical (or lumbar) vertebral region were recorded from the biceps, thenar and tibialis anterior muscles in 30 patients with cervical spondylosis. Twelve normal controls were matched for age and height. Abnormalities of central motor conduction (absence or increased central delay of cortical responses) for at least one muscle were observed in all (but one) the patients with myelopathy alone or combined with radiculopathy. An increase in latency of the responses evoked by cervical stimulation occurred in 40% of patients with radiculopathy or myelo-radiculopathy. Changes of motor conduction occurred even in the absence of abnormalities of somatosensory evoked potentials, while the opposite was never observed. Direct stimulation of the motor tracts may be of value in the functional assessment of the motor pathways in cervical spondylosis.