Ocular counterrolling abnormalities in spasmodic torticollis

Spasmodic torticollis is a focal dystonic movement disorder of unknown origin, long hypothesized to have some vestibular involvement. An examination of otolith function, ocular counterrolling, was performed on eight patients with this disorder. The test consisted of photographing both eyes while the subject underwent rotation in both naso-occipital and earth-horizontal long axes. Measurements of eye torsion were made with a superimposition technique accurate to 0.1 degrees. Results showed all eight patients had abnormal ocular counterrolling. The most notable defect was the lack of sustained eye torsion at the extreme positions, resulting in rolling of the eyes in the direction of head tilt rather than counterrolling, a phenomenon previously observed only in persons with known brain-stem problems. That finding, as well as the majority of the patients showing spontaneous vestibular nystagmus in the dark and directional preponderance with caloric stimulation, implies that one difficulty in spasmodic torticollis lies in central vestibular connections, manifested by disruption of brain-stem pathways.

Multi-center study of Parkinson mortality with early versus later dopa treatment

Four geographically diverse centers provided data on mortality in 359 patients with Parkinson's disease, the majority of whom began dopa treatment during the early experimental trials of 1968 to 1970. Patients were classified into three groups based on the duration of symptoms prior to starting dopa treatment: Group 1, 1 to 3 years; Group 2, 4 to 6 years; Group 3, 7 to 9 years. After 15 years of treatment and 3,689 person-years of observation, Group 1 had an observed-to-expected mortality ratio of 1.43; Group 2, 2.44; and Group 3, 2.95 (p less than 0.05). This result confirmed that increased duration of disease was associated with increased mortality risk. To examine the effect of the time of initiation of dopa treatment, duration of disease was held constant at 17 years for all three groups. Observed-to-expected mortality ratios were 1.43 for Group 1; 2.66 for Group 2; 2.63 for Group 3. This statistically significant advantage for Group 1 (p less than 0.0001) led to the conclusion that early treatment with dopa has a beneficial effect on life expectancy. After 17 years of disease, causes of death in Group 1 were less likely (p = 0.027) to be due to Parkinson's disease than was found in the other groups.

Parkinson's disease: sensory and motor problems in arms and hands

Fifteen undemented patients with Parkinson's disease (PD) and 15 age-matched controls were given a battery of tests to assess sensorimotor integration in the arms. PD patients made more errors (p less than 0.01) than controls, particularly in tests of proprioception. Age was not related to errors. Compared with controls, two-point discrimination thresholds were significantly higher (p less than 0.02) on the index finger of PD patients, but not on the forearm. Results confirm the sensorimotor deficits found earlier in an orofacial study, and imply that PD involves a generalized dysfunction of sensorimotor integration and proprioception, probably a result of impaired basal ganglia function in processing and integrating sensory input to organize and guide movement.

Long-term follow-up of early dopa treatment in Parkinson's disease

A group of 19 patients with Parkinson's disease, who began dopa therapy 1 to 3 years after onset of symptoms, were followed for 12 years. They were evaluated every 3 to 4 months on the UCLA disability scale and the Hoehn and Yahr functional classification scale. This present group was compared to two other historical groups reported on earlier [8], one that began treatment with dopa 4 to 6 years after onset of symptoms and the other that began dopa treatment 7 to 9 years after onset of symptoms. Results on both scales showed that the mean disability scores of the three groups did not differ significantly when duration of disease was matched, even though duration of dopa therapy among the groups varied from 1 to 12 years. The highly significant differences between the groups prior to dopa treatment continued throughout the study. These longitudinal data support the conclusion that the worsening over time is the result of progression of Parkinson's disease and not a result of the duration of dopa treatment. Early treatment improves the beginning years of the disease and has no adverse effect on later years. Twelve years after beginning dopa therapy, 32% of the present group had died at a mean age of 76.0, in contrast to 50% (mean age, 74.7) and 57% (mean age, 71.5) in the groups who began dopa increasingly later in the course of their disease. Incidence of dementia increased with disease duration regardless of treatment duration.(ABSTRACT TRUNCATED AT 250 WORDS)

Deficits in orofacial sensorimotor function in Parkinson's disease

Orofacial sensorimotor function was assessed in patients with Parkinson's disease and in age-matched controls. Tests were designed to assess sensory function, motor abilities, and the integration of sensory information for the performance of specific movements. Patients with Parkinson's disease and normal subjects both made more errors with increasing age; however, overall, patients with Parkinson's disease made significantly more errors in our tests than did normal subjects. Interestingly, patients with Parkinson's disease showed greater deficits in tests of sensory function and sensorimotor integration than in tests of motor function. These results suggest that one aspect of Parkinson's disease consists of complex deficits in the utilization of specific sensory inputs to organize and guide movements. The results are further discussed in relation to a proposed sensory gating or filtering schema of basal ganglia motor functioning.

Double-blind trial of pergolide for Parkinson's disease

Pergolide mesylate, a dopamine agonist, was studied as adjunctive therapy in a 6-month double-blind trial in 20 patients with Parkinson's disease who were achieving less than optimal response from Sinemet. As pergolide or placebo was administered in increasing dosage, Sinemet was reduced if side effects developed. Both the pergolide and placebo groups improved significantly (p less than 0.05). The pergolide group improved 30% at the end of 24 weeks, and the placebo group 23%. There was no significant difference between drug and placebo groups, possibly due to a fortuitous support group and the side effects that may have burdened the pergolide group. Nevertheless, pergolide had a definite antiparkinsonian effect.

Ocular counterrolling as an indicator of vestibular otolith function

Sixteen normal subjects, 8 patients with unilateral vestibular nerve section, and 11 patients with acoustic neuromas underwent dynamic ocular counterrolling (OCR) testing. Both eyes were photographed at every 10 degrees as the subject was tilted about the naso-occipital axis at a constant velocity of 3 degrees/sec. Normal subjects differed from patients in four characteristics: (1) The binocular OCR patterns of normal subjects were consistent from one trial to the next. (2) The two eyes were mostly conjugate in movement. (3) The patterns were smooth. (4) OCR was approximately symmetric to right and left tilts. In the patients, patterns were abnormal when tilted to the side opposite the lesion. In quantified measures of the four characteristics, differences between the normal group and the group of patients with unilateral vestibular nerve sections were significant in consistency and total scores. In the patients with acoustic neuromas, OCR abnormalities corresponded to the size and location of the tumors and the extent to which they impinged on the utricular nerve and brainstem.

Evaluating the evaluations: or how to weigh the scales of parkinsonian disability

We used four disability scales to evaluate eight patients with Parkinson's disease who were treated with pergolide mesylate for 1 year. Disability was rated on all four scales by the same neurologist at each of 11 visits. Prior ratings were not available to the examiner, who did not know that the scales themselves were an object of study. Disability scores, converted to percentage improvement relative to baseline, varied considerably between scales; for instance, at 5 months, one showed 13% improvement and another 58%. At 9 months, one showed worsening of 6% and another showed improvement of 34%. The four disability scales clearly measure different aspects of parkinsonism, and comparing results of different studies may not be valid if the disability scales are not the same.

Binocular counterrolling during sustained body tilt in normal humans and in a patient with unilateral vestibular nerve section

Two normal persons and a patient with unilateral vestibular nerve section were held motionless for ten minutes in the upright position, at 60 degrees tilt right ear down, and at 60 degrees tilt left ear down. In addition, one normal subject was held for ten minutes at each of 30, 60, and 90 degrees tilt left ear down. Photographs were taken of both eyes every ten seconds. Measurements of ocular counterrolling during these trials revealed torsional eye movements in all positions, including the upright, even though the head and body were stationary. Variations in torsion in the upright position ranged up to 2.75 degrees. At the tilt positions, variations ranged up to 4 degrees. Disconjugate movements were seen in all subjects in all positions. There were no significant differences in measurements of ocular counterrolling during static tilt between the normal subjects and the patient with the vestibular nerve section, in contrast to measures obtained during slow velocity dynamic testing.

Evidence to support early levodopa therapy in Parkinson disease

To see whether duration of disease or of levodopa treatment was responsible for gradual worsening of parkinsonian patients, 58 persons treated with levodopa were classified into three groups based on predopa disease duration. Data over 6 years of treatment showed that disease duration was the determining factor. Patients matched for disease duration had similar disability scores regardless of duration of therapy. Matched for therapy duration, patients with longer disease duration had consistently higher disability scores. Side effects showed no differences between groups and did not increase over time. In sum, delaying therapy fails to improve disability in the early years of disease and does not confer any benefit in later years.

Binocular counterrolling in humans during dynamic rotation

Seven subjects 18 to 66 years old underwent 360 degrees rotation at a constant velocity of 3 degrees/sec, in 27 trials beginning randomly right ear down or left ear down. A camera on the rotating chair photographed both eyes every 10 degrees. Dual projectors measured counterrolling, the image from one projector being aligned and rotated until it was superimposed on the image from the other. Right and left eyes were measured independently. The group reached maximum counterrolling at about 70 degrees and 270 degrees in rotations to the right, with values of about -6 degrees and 4 degrees respectively. Rotations to the left reached maximum at 50 degrees and 270 degrees with about 4.5 degrees and -5.25 degrees respectively. Individual subjects showed ranges of counterrolling varying from 4.03 degrees to 17.44 degrees, mean 11.30 degrees. More counterrolling was observed when subjects were tilted to right than to left. The downward eye counterrolled more than the upward. Amount of counterrolling was inversely correlated with age.

A double-blind comparison of levodopa, Madopa, and Sinemet in Parkinson disease

A sixteen-week study examined the effect of Madopa and Sinemet on patients with Parkinson disease disease suffering nausea or vomiting as side-effects of levodopa therapy and compared the efficacy of the three preparations in controlling the symptoms of Parkinson disease. Following a control period on levodopa, 20 patients underwent four consecutive four-week regimens as follows: (1) double-blind, in which a randomized half received levodopa and half received Madopa; (2) single-blind, in which all received Madopa; (3) double-blind, in which a re-randomized half received Madopa and half Sinemet; and (4) single-blind, in which all received Sinemet. Levodopa administration via Sinemet and Madopa was held to a fixed 20% of prior levodopa dosage. Almost all patients showed great reduction in nausea and vomiting with both Madopa and Sinemet. Seventy percent of the patients showed improvement in disability compared to their levodopa baseline levels. Group means showed no difference between the improvement seen on Madopa and that seen on Sinemet. However, examination of individual responses showed that the majority of patients fared distinctly better on either Sinemet or Madopa.

Ocular accomodative changes in humans induced by positional changes with respect to gravity

Ocular accomodation was measured in human subjects while they were rotated at 1 degree/sec about their naso-occipital axes. Sixteen normal subjects were tested with 45 complete and 27 partial revolutions. Naso-occipital rotations ipsilateral to the eye being observed caused accommodative, lens-thickening changes. This effect begin at about 14 degrees from head upright position, tended to reach a maximum by 45 degrees and usually stayed at this level until about 90 degrees. The values tended to return to control level by 180 degrees. With naso-occipital roll in the direction opposite to the eye being observed, there was little change until about 135 degrees at which point further roll was typically clear accomodation. This continued to a maximum at about 270 degrees rotation, and at about 350 degrees returned to control values. Arguments are presented relating this response to the utricles, which are approximately parallel to earth horizontal. The threshold of this response, between 3.7 and 77 cm/sec2, is similar to the threshold of linear acceleration when measured by other means.

Present morality in parkinson's disease: the ratio of observed to expected deaths with a method to calculate expected deaths

Excess mortality, i.e. more deaths than expected in a similar normal population, has been reduced in Parkinson's disease by levodopa. A California series and a large collaborative study throughout the United States show the ratio of observed to expected deaths to be normal. In contrast, a New York study was similar patients and a Montreal group of much more severely disabled patients showed greater mortality. The reasons for these differences are unclear, but some variations in results may be attributed to different methods of calculating expected deaths to derive the ratio of observed to expected deaths.

Parkinson's disease and levodopa. A five-year follow-up and review

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