Decrease in presynaptic inhibition on heteronymous monosynaptic Ia terminals in patients with Parkinson's disease

Temporal Investigations of the Changes in Presynaptic Inhibition Associated With Subthalamic Nucleus-Deep-Brain Stimulation

BACKGROUND AND PURPOSE

There are controversies regarding the role of presynaptic inhibition (PSI) in the mechanisms underlying the efficacy of deep-brain stimulation (DBS) in Parkinson's disease (PD). We sought to determine the involvement of PSI in DBS-related mechanisms and clinical correlates.

METHODS

We enrolled PD subjects who had received subthalamic nucleus DBS (STN-DBS) therapy and had been admitted to our clinic between January 2022 and March 2022. The tibial H-reflex was studied bilaterally during the medication-off state, and all tests were repeated 10 and 20 minutes after the simulation was turned off. Simultaneous evaluations based on the Movement-Disorder-Society-sponsored revision of the Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III) were performed in all of the patients.

RESULTS

Ultimately we enrolled 18 patients aged 58.7±9.3 years (mean±standard deviation, 10 females). Fifty percent of the patients showed a decrease in the MDS-UPDRS-III score of more than 60% during the stimulation-on period. Comparative analyses of the repeated measurements made according to the stimulation status revealed significant differences only in the left H-reflex/M-response amplitude ratio (H/M ratio). However, no difference in the left H/M ratio was found in the subgroup of patients with a prominent clinical response to stimulation (n=9). Analyses of the less-affected side revealed differences in the H-reflex amplitude and H/M ratio.

CONCLUSIONS

We found evidence of PSI recovery on the less-affected side of our PD subjects associated with STN-DBS. We hypothesize that the involvement of this spinal pathway and its contribution to the mechanisms of DBS differ between individuals based on the severity of the disease and which brainstem regions and descending tracts are involved.

Participant attention on the intervention target during repetitive passive movement improved spinal reciprocal inhibition enhancement and joint movement function

This study aimed to evaluate the effects of the participant's attention target during repetitive passive movement (RPM) intervention on reciprocal inhibition (RI) and joint movement function. Twenty healthy adults participated in two experiments involving four attention conditions [control (forward attention with no RPM), forward attention (during RPM), monitor attention (monitor counting task during RPM), ankle joint attention (ankle movement counting task during RPM)] during 10-min RPM interventions on the ankle joint. Counting tasks were included to ensure the participant's attention remained on the target during the intervention. In Experiment 1, RI was measured before, immediately after, and 5, 10, 15, 20, and 30 min after the RPM intervention. In Experiment 2, we evaluated ankle joint movement function at the same time points before and after RPM intervention. The maximum ankle dorsiflexion movement (from 30° plantar flexion to 10° dorsiflexion) was measured, reflecting RI. In Experiment 1, the RI function reciprocal Ia inhibition was enhanced for 10 min after RPM under all attention conditions (excluding the control condition. D1 inhibition was enhanced for 20 min after RPM in the forward and monitor attention conditions and 30 min after RPM in the ankle joint attention condition. In Experiment 2, the joint movement function decreased under the forward and monitor attention conditions but improved under the ankle joint attention condition. This study is the first to demonstrate that the participant's attention target affected the intervention effect of the RI enhancement method, which has implications for improving the intervention effect of rehabilitation.

Investigation of the changes in the presynaptic inhibition in association with the subthalamic nucleus stimulation in Parkinson's disease

BACKGROUND AND PURPOSE

Presynaptic inhibition (PSI) is a critical spinal inhibitory mechanism for modulating muscle coordination by adjusting both supraspinal motor commands and sensory feedback at the spinal level. The literature data regarding the role of PSI in the efficiency of STN-DBS therapy in Parkinson's disease (PD) are limited. We aimed to investigate the possible alteration in this pathway in association with the STN stimulation (STIM) within the very early period after the STIM is off.

METHODS

We performed the H-reflex investigation on 8 PD subjects with STN-DBS who applied to our polyclinic for routine clinical evaluations. The investigations were initially performed at the STIM-on period and repeated after the STIM set is off for 5 min. A within-subjects ANOVA was used to test for a significant difference between the STIM-on and -off states for the variables of (repeated measures) H-latency, H amplitude, M amplitude, H/M amplitude, H threshold, and M threshold.

RESULTS

The results of the analyses did not reveal marked changes in the variables of the H-reflex between the STIM-on and -off states.

CONCLUSION

PSI do not alter in the very early period after the STIM is off. Taken together with the related literature data and our study results, it can be hypothesized that the PSI might involve in the DBS efficiency in the later phase of the STIM as a compensatory mechanism. Further prospective studies including a larger number of patients with serial electrophysiological recordings to investigate the temporal course of the underlying dynamics are required to clarify these discussions.

Effects of Clenching Strength on Exercise Performance: Verification Using Spinal Function Assessments

BACKGROUND

This study aimed to determine the relationship between exercise performance and spinal function based on clenching strength.

HYPOTHESIS

Low-intensity clenching contributes to joint movement, whereas high-intensity clenching contributes to joint fixation.

STUDY DESIGN

Randomized crossover trial.

LEVEL OF EVIDENCE

Level 3.

METHODS

Two experiments were conducted using 2 groups of 20 healthy adults. The 4 clenching conditions in experiment 1 were 0%, 12.5%, 25%, and 50% of the maximum voluntary contraction (MVC) of the masseter muscle. Experiment 2 consisted of 3 conditions: no-bite condition, moderate effort, and maximum effort (max condition). In experiment 1, spinal function and ankle dorsiflexion tasks were measured for each clenching condition, and the ankle dorsiflexion task was measured in experiment 2. Regarding spinal function, we measured spinal reciprocal inhibition (RI) and excitability of spinal anterior horn cells. For the ankle dorsiflexion task, ankle dorsiflexion MVC was performed for 3 seconds under each clenching condition. The items analyzed were reaction time, peak ankle dorsiflexion torque, and soleus (Sol)/tibialis anterior (TA) electromyography (EMG) ratio.

RESULTS

The results of experiment 1 illustrated that RI was significantly attenuated or eliminated with increasing clenching strength (>25% MVC). Spinal anterior horn cell excitability increased significantly with increasing clenching strength. The peak torque was significantly higher at 50% MVC than that at 0% MVC. In experiment 2, the peak torque was significantly higher under moderate and max conditions than no-bite condition, and the Sol/TA EMG ratio was significantly higher under max condition than that under moderate condition.

CONCLUSION/CLINICAL RELEVANCE

The results illustrated that during high-strength clenching (≥50% MVC), antagonist muscles are activated simultaneously to increase muscle strength. High-strength clenching improved kinetic performance (joint fixation), whereas low-strength clenching (<50% MVC) enhanced exercise performance (joint movement).

Activation of the Supplementary Motor Areas Enhances Spinal Reciprocal Inhibition in Healthy Individuals

The supplementary motor area (SMA) may modulate spinal reciprocal inhibition (RI) because the descending input from the SMA is coupled to interneurons in the spinal cord via the reticulospinal tract. Our study aimed to verify whether the anodal transcranial direct current stimulation (anodal-tDCS) of the SMA enhances RI. Two tDCS conditions were used: the anodal stimulation (anodal-tDCS) and sham stimulation (sham-tDCS) conditions. To measure RI, there were two conditions: one with the test stimulus (alone) and the other with the conditioning-test stimulation intervals (CTIs), including 2 ms and 20 ms. RI was calculated at multiple time points: before the tDCS intervention (Pre); at 5 (Int 5) and 10 min; and immediately after (Post 0); and at 5, 10 (Post 10), 15, and 20 min after the intervention. In anodal-tDCS, the amplitude values of H-reflex were significantly reduced for a CTI of 2 ms at Int 5 to Post 0, and a CTI of 20 ms at Int 5 to Pot 10 compared with Pre. Stimulation of the SMA with anodal-tDCS for 15 min activated inhibitory interneurons in RIs by descending input from the reticulospinal tract via cortico–reticulospinal projections. The results showed that 15 min of anodal-tDCS in the SMA enhanced and sustained RI in healthy individuals.

Loss of presynaptic inhibition for step initiation in parkinsonian individuals with freezing of gait

KEY POINTS

Individuals with freezing of gait (FoG) due to Parkinson's disease (PD) have small and long anticipatory postural adjustments (APAs) associated with delayed step initiation. Individuals with FoG ('freezers') may require functional reorganization of spinal mechanisms to perform APAs due to supraspinal dysfunction. As presynaptic inhibition (PSI) is centrally modulated to allow execution of supraspinal motor commands, it may be deficient in freezers during APAs. We show that freezers presented PSI in quiet stance (control task), but they presented loss of PSI (i.e. higher ratio of the conditioned H-reflex relative to the test H-reflex) during APAs before step initiation (functional task), whereas non-freezers and healthy control individuals presented PSI in both the tasks. The loss of PSI in freezers was associated with both small APA amplitudes and FoG severity. We hypothesize that loss of PSI during APAs for step initiation in freezers may be due to FoG.

ABSTRACT

Freezing of gait (FoG) in Parkinson's disease involves deficient anticipatory postural adjustments (APAs), resulting in a cessation of step initiation due to supraspinal dysfunction. Individuals with FoG ('freezers') may require functional reorganization of spinal mechanisms to perform APAs. As presynaptic inhibition (PSI) is centrally modulated to allow execution of supraspinal motor commands, here we hypothesized a loss of PSI in freezers during APA for step initiation, which would be associated with FoG severity. Seventy individuals [27 freezers, 22 non-freezers, and 21 age-matched healthy controls (HC)] performed a 'GO'-commanded step initiation task on a force platform under three conditions: (1) without electrical stimulation, (2) test Hoffman reflex (H-reflex) and (3) conditioned H-reflex. They also performed a control task (quiet stance). In the step initiation task, the H-reflexes were evoked on the soleus muscle when the amplitude of the APA exceeded 10-20% of the mean baseline mediolateral force. PSI was quantified by the ratio of the conditioned H-reflex relative to the test H-reflex in both the tasks. Objective assessment of FoG severity (FoG-ratio) was performed. Freezers presented lower PSI levels during quiet stance than non-freezers and HC (P < 0.05). During step initiation, freezers presented loss of PSI and lower APA amplitudes than non-freezers and HC (P < 0.05). Significant correlations were only found for freezers between loss of PSI and FoG-ratio (r = 0.59, P = 0.0005) and loss of PSI and APA amplitude (r = -0.35, P < 0.036). Our findings suggest that loss of PSI for step initiation in freezers may be due to FoG.

Effects of Reciprocal Ia Inhibition on Contraction Intensity of Co-contraction

Introduction: Excessive co-contraction interferes with smooth joint movement. One mechanism is the failure of reciprocal inhibition against antagonists during joint movement. Reciprocal inhibition has been investigated using joint torque as an index of intensity during co-contraction. However, contraction intensity as an index of co-contraction intensity has not been investigated. In this study, we aimed to evaluate the influence of changes in contraction intensity during co-contraction on reciprocal inhibition.

Methods: We established eight stimulus conditions in 20 healthy adult males to investigate the influence of changes in contraction intensity during co-contraction on reciprocal inhibition. These stimulus conditions comprised a conditioning stimulus-test stimulation interval (C–T interval) of -2, 0, 1, 2, 3, 4, or 5 ms plus a test stimulus without a conditioning stimulus (single). Co-contraction of the tibialis anterior and soleus muscles at the same as contraction intensity was examined at rest and at 5, 15, and 30% maximal voluntary contraction (MVC).

Results: At 5 and 15% MVC in the co-contraction task, the H-reflex amplitude was significantly decreased compared with single stimulation at a 2-ms C–T interval. At 30% MVC, there was no significant difference compared with single stimulation at a 2-ms C–T interval. At a 5-ms C–T interval, the H-reflex amplitude at 30% MVC was significantly reduced compared with that at rest.

Discussion: The findings indicated that during co-contraction, reciprocal Ia inhibition worked at 5 and 15% MVC. Contrary inhibition of reciprocal Ia inhibition did not apparently work at 30% MVC, and presynaptic inhibition (D1 inhibition) might work.

Balance and fear of falling in subjects with Parkinson's disease is improved after exercises with motor complexity

Resistance training with instability (RTI) uses exercises with high motor complexity that impose high postural control and cognitive demands that may be important for improving postural instability and fear of falling in subjects with Parkinson's disease (PD). Here, we hypothesized that: 1) RTI will be more effective than resistance training (RT) in improving balance (Balance Evaluation Systems Test [BESTest] and overall stability index [Biodex Balance System^®]) and fear of falling (Falls Efficacy Scale-International [FES-I] score) of subjects with Parkinson's disease (PD); and 2) changes in BESTest and FES-I after RTI will be associated with changes in cognitive function (Montreal Cognitive Assessment [MoCA] score - previously published) induced by RTI. Thirty-nine subjects with moderate PD were randomly assigned to a nonexercising control, RT, and RTI groups. While RT and RTI groups performed progressive RT twice a week for 12 weeks, the RTI group added progressive unstable devices to increase motor complexity of the resistance exercises. There were significant group × time interactions for BESTest, overall stability index, and FES-I scores (P < 0.05). Only RTI improved BESTest, overall stability index and FES-I scores, and RTI was more effective than RT in improving biomechanical constraints and stability in gait (BESTest sections) at post-training (P < 0.05). There were strong correlations between relative changes in BESTest and MoCA (r = 0.72, P = 0.005), and FES-I and MoCA (r = -0.75, P = 0.003) after RTI. Due to the increased motor complexity in RTI, RTI is recommended for improving balance and fear of falling, which are associated with improvement in cognitive function of PD.

Functions and dysfunctions of the basal ganglia in humans

Involuntary movements and parkinsonism have been interesting and important topics in neurology since the last century. The development of anatomical and physiological studies of the neural circuitry of motor systems has encouraged the study of movement disorders by means of pathophysiology and brain imaging.Multichannel electromyography from affected muscles has generated objective and analytical data on chorea, ballism, athetosis, and dystonia. Studies using floor reaction forces revealed the pathophysiology of freezing of gait in parkinsonism. Akinesia and bradykinesia are attributable to dysfunctions in the basal ganglia, frontal lobe, and parieto-occipital visual association cortex.Reciprocal innervation is an essential mechanism of smooth voluntary movement. Spinal reflexes on reciprocal innervation has been investigated in awake humans, and the pathophysiology of spasticity and Parkinson's disease were revealed as a result. Clinical applications for the treatment and evaluation of status have been developed.For future studies, detailed neural mechanisms underlying the development of motor disorders in basal ganglia diseases and recovery by interventions including surgery and neurorehabilitation are important.

A Role for Dystonia-Associated Genes in Spinal GABAergic Interneuron Circuitry

Spinal interneurons are critical modulators of motor circuit function. In the dorsal spinal cord, a set of interneurons called GABApre presynaptically inhibits proprioceptive sensory afferent terminals, thus negatively regulating sensory-motor signaling. Although deficits in presynaptic inhibition have been inferred in human motor diseases, including dystonia, it remains unclear whether GABApre circuit components are altered in these conditions. Here, we use developmental timing to show that GABApre neurons are a late Ptf1a-expressing subclass and localize to the intermediate spinal cord. Using a microarray screen to identify genes expressed in this intermediate population, we find the kelch-like family member Klhl14, implicated in dystonia through its direct binding with torsion-dystonia-related protein Tor1a. Furthermore, in Tor1a mutant mice in which Klhl14 and Tor1a binding is disrupted, formation of GABApre sensory afferent synapses is impaired. Our findings suggest a potential contribution of GABApre neurons to the deficits in presynaptic inhibition observed in dystonia.

Resistance training with instability is more effective than resistance training in improving spinal inhibitory mechanisms in Parkinson's disease

This study assessed 1) the effects of 12 wk of resistance training (RT) and resistance training with instability (RTI) on presynaptic inhibition (PSI) and disynaptic reciprocal inhibition (DRI) of patients with Parkinson's disease (PD); 2) the effectiveness of RT and RTI in moving PSI and DRI values of patients toward values of age-matched healthy controls (HC; Z-score analysis); and 3) associations between PSI and DRI changes and clinical outcomes changes previously published. Thirteen patients in RT group, 13 in RTI group, and 11 in a nonexercising control group completed the trial. While RT and RTI groups performed resistance exercises twice a week for 12 wk, only the RTI group used unstable devices. The soleus H reflex was used to evaluate resting PSI and DRI before and after the experimental protocol. The HC (n = 31) was assessed at pretest only. There were significant group × time interactions for PSI (P < 0.0001) and DRI (P < 0.0001). RTI was more effective than RT in increasing the levels of PSI (P = 0.0154) and DRI (P < 0.0001) at posttraining and in moving PSI [confidence interval (CI) 0.1-0.5] and DRI (CI 0.6-1.1) levels to those observed in HC. There was association between DRI and quality of life changes (r = -0.69, P = 0.008) and a strong trend toward association between PSI and postural instability changes (r = 0.60, P = 0.051) after RTI. RTI increased PSI and DRI levels more than RT, reaching the average values of the HC. Thus RTI may cause plastic changes in PSI and DRI pathways that are associated with some PD clinical outcomes.

NEW & NOTEWORTHY

Patients with Parkinson's disease (PD) have motor dysfunction. Spinal inhibitory mechanisms are important for modulating both supraspinal motor commands and sensory feedback at the spinal level. Resistance training with instability was more effective than resistance training in increasing the levels of presynaptic inhibition and disynaptic reciprocal inhibition of lower limb at rest of the patients with PD, reaching the average values of the healthy controls.

Independent control of presynaptic inhibition by reticulospinal and sensory inputs at rest and during rhythmic activities in the cat

To be functionally relevant during movement, the transmission from primary afferents must be efficiently controlled by presynaptic inhibition. Sensory feedback, central pattern generators, and supraspinal structures can all evoke presynaptic inhibition, but we do not understand how these inputs interact during movement. Here, we investigated the convergence of inputs from the reticular formation and sensory afferents on presynaptic inhibitory pathways and their modulation at rest and during two fictive motor tasks (locomotion and scratch) in decerebrate cats. The amplitude of primary afferent depolarization (PAD), an estimate of presynaptic inhibition, was recorded in individual afferents with intra-axonal recordings and in a mix of afferents in lumbar dorsal rootlets (dorsal root potential [DRP]) with bipolar electrodes. There was no spatial facilitation between inputs from reticulospinal and sensory afferents with DRPs or PADs, indicating an absence of convergence. However, spatial facilitation could be observed by combining two sensory inputs, indicating that convergence was possible. Task-dependent changes in the amplitude of responses were similar for reticulospinal and sensory inputs, increasing during fictive locomotion and decreasing during fictive scratch. During fictive locomotion, DRP and PAD amplitudes evoked by reticulospinal inputs were increased during the flexion phase, whereas sensory-evoked DRPs and PADs showed maximal amplitude in either flexion or extension phases. During fictive scratch, the amplitudes of DRPs and PADs evoked by both sources were maximal in flexion. The absence of spatial facilitation and different phase-dependent modulation patterns during fictive locomotion are consistent with independent presynaptic inhibitory pathways for reticulospinal and sensory inputs.

Changes in correlation between spontaneous activity of dorsal horn neurones lead to differential recruitment of inhibitory pathways in the cat spinal cord

Simultaneous recordings of cord dorsum potentials along the lumbo-sacral spinal cord of the anaesthetized cat revealed the occurrence of spontaneous synchronous negative (n) and negative-positive (np) cord dorsum potentials (CDPs). The npCDPs, unlike the nCDPs, appeared preferentially associated with spontaneous negative dorsal root potentials (DRPs) resulting from primary afferent depolarization. Spontaneous npCDPs recorded in preparations with intact neuroaxis or after spinalization often showed a higher correlation than the nCDPs recorded from the same pair of segments. The acute section of the sural and superficial peroneal nerves further increased the correlation between paired sets of npCDPs and reduced the correlation between the nCDPs recorded from the same pair of segments. It is concluded that the spontaneous nCDPs and npCDPs are produced by the activation of interconnected sets of dorsal horn neurones located in Rexed's laminae III–IV and bilaterally distributed along the lumbo-sacral spinal cord. Under conditions of low synchronization in the activity of this network of neurones there would be a preferential activation of the intermediate nucleus interneurones mediating Ib non-reciprocal postsynaptic inhibition. Increased synchronization in the spontaneous activity of this ensemble of dorsal horn neurones would recruit the interneurones mediating primary afferent depolarization and presynaptic inhibition and, at the same time, reduce the activation of pathways mediating Ib postsynaptic inhibition. Central control of the synchronization in the spontaneous activity of dorsal horn neurones and its modulation by cutaneous inputs is envisaged as an effective mechanism for the selection of alternative inhibitory pathways during the execution of specific motor or sensory tasks.

The effects of external cues on ankle control during gait initiation in Parkinson's disease

The present study investigated the effects of external cues on motor control of the ankle joint during gait initiation in patients with Parkinson's disease (PD) and in age-matched healthy subjects. The soleus H-reflexes were recorded during self-generated and cue-triggered gait initiation. The tibialis anterior muscle burst during cue-triggered gait initiation was found to be significantly larger than that during self-generated gait initiation in both groups. External cues significantly increased soleus H-reflex depression during gait initiation in PD patients, although this significant increase was not present in healthy subjects. These findings indicate that external cues affect motor control of the extensor muscle of the ankle joint during gait initiation in PD patients.

Paradoxical modulation of tendon tap reflex during voluntary contraction in Parkinson's disease

OBJECTIVE

Inadequate supraspinal modulation of spinal motor control mechanisms such as alpha-gamma coactivation is supposed to cause difficulty in maintaining proper voluntary contraction in Parkinson's disease (PD).

METHODS

Subjects were 42 patients with PD and 20 normal volunteers. Soleus H-reflex and tendon tap reflex (T-reflex) were recorded. The maximal reflexes (H(max) and T(max)) at rest were recorded first. Next, the stimulus intensities were fixed to obtain a reflex size of around 25% of M(max) at rest for both H- and T-reflexes, and the reflexes were recorded at rest, during tonic plantarflexion (TPF), and at the onset of plantarflexion.

RESULTS

H(max) at rest was 55% and T(max) 30% in normal subjects, while they were 36 and 31%, respectively, in PD. The size ratio of T(max) and H(max) at rest in PD was larger than normal. In PD, the size of H-reflex increased with TPF as in normal subjects, but T-reflex decreased. These changes in T-reflex were correlated with the grade of rigidity, bradykinesia, and time for 10 m gait. H-reflex had no such correlations.

CONCLUSIONS

T-reflex was abnormally modulated in PD especially during tonic contraction.

SIGNIFICANCE

Inappropriate supraspinal modulation of the spinal reflex pathways disturbs motor performance in PD.

Soleus H-reflex inhibition during gait initiation in Parkinson's disease

The soleus H-reflex excitability during gait initiation was investigated in Parkinson's disease. Eleven patients participated in this study. Patients stepped forward as soon as the start signal flashed. Soleus H-reflex was evoked from the trailing leg 100, 300, or 600 msec after the start signal. The electromyographic activity in the soleus muscle immediately before evoking the H-reflex and the ankle joint motion were recorded. The soleus H-reflex was inhibited 300 msec after the start signal. The amount of the soleus H-reflex inhibition was inversely correlated with the Hoehn and Yahr stage; Items 14, 29, and 31 of the Unified Parkinson's Disease Rating Scale; and the delay of the onset of the ankle dorsiflexion from the start signal. In contrast, the amount of electromyographic activity immediately before evoking the H-reflex was not significantly correlated with those measures but was significantly correlated with Item 22 of the Unified Parkinson's Disease Rating Scale. Those findings indicate that the amount of soleus H-reflex inhibition during gait initiation depends on the severity of the disease. Abnormality of descending command may be related to the severity-dependent H-reflex inhibition.

Parkinson?s disease: clinical aspects

Parkinsonism is a clinical syndrome characterized by akinesia, muscular rigidity, and resting tremor. The most frequent cause of parkinsonism is Parkinson's disease (PD). Progressive loss of substantia nigra neurons together with the occurrence of Lewy bodies are considered essential neuropathological features of PD. Recent neuropathological studies suggest that nigral degeneration is only part of a more extended brain degeneration that starts in the medulla oblongata and then spreads to the mesencephalon and cerebral cortex. Correspondingly, the clinical symptoms occurring in PD go far beyond parkinsonism. Depending on the disease stage, autonomic dysfunction, olfactory disturbances, depression, and dementia are frequently encountered in PD. These neuropathological and clinical observations have major implications for future research in PD. In particular, the analysis of the properties that the neuronal cell types involved in PD have in common and that might make them susceptible to degeneration is essential.

The basal ganglia network mediates the planning of movement amplitude

This study addresses the hypothesis that the basal ganglia (BG) are involved specifically in the planning of movement amplitude (or covariates). Although often advanced, based on observations that Parkinson's disease (PD) patients exhibit hypokinesia in the absence of significant directional errors, this hypothesis has been challenged by a recent alternative, that parkinsonian hypometria could be caused by dysfunction of on-line feedback loops. To re-evaluate this issue, we conducted two successive experiments. In the first experiment we assumed that if BG are involved in extent planning then PD patients (who exhibit a major dysfunction within the BG network) should exhibit a preserved ability to use a direction precue with respect to normals, but an impaired ability to use an amplitude precue. Results were compatible with this prediction. Because this evidence did not prove conclusively that the BG is involved in amplitude planning (functional deficits are not restricted to the BG network in PD), a second experiment was conducted using positron emission tomography (PET). We hypothesized that if the BG is important for planning movement amplitude, a task requiring increased amplitude planning should produce increased activation in the BG network. In agreement with this prediction, we observed enhanced activation of BG structures under a precue condition that emphasized extent planning in comparison with conditions that emphasized direction planning or no planning. Considered together, our results are consistent with the idea that BG is directly involved in the planning of movement amplitude or of factors that covary with that parameter.

Basal ganglia network mediates the control of movement amplitude

In the present study we address the hypothesis that the basal ganglia are specifically involved in the planning of movement amplitude (or related covariates). This prediction has often been put forward based on the observation that Parkinson's disease (PD) patients exhibit hypokinesia. A close examination of the literature shows, however, that this commonly reported clinical symptom is not consistently echoed by experimental observations. When required to point to visual targets in the absence of vision of the moving limb, PD subjects exhibit various patterns of inaccuracy, including hypometria, hypermetria, systematic direction bias, or direction-dependent errors. They have even been shown to be as accurate as healthy, age-matched subjects. The main aim of the current study is to address the origin of these inconsistencies. To this end, we required nine patients presenting with advanced PD and 15 age-matched control subjects to perform planar reaching movements to visual targets. Eight targets were presented in equally spaced directions around a circle centered on the hand's starting location. Based on a previously validated parsing procedure, end-point errors were segmented into localization and planning errors. Localization errors refer to the existence of systematic biases in the estimation of the initial hand location. These biases can potentially transform a simple pattern of pure amplitude errors into a complex pattern involving both amplitude and direction errors. Results indicated that localization errors were different in the PD patients and the control subjects. This is not surprising knowing both that proprioception is altered in PD patients and that the ability to locate the hand at rest relies mainly on the proprioceptive sense, even when vision is available. Unlike normal subjects, localization errors in PD were idiosyncratic, lacking a consistent pattern across subjects. When the confounding effect of initial hand localization errors was canceled, we found that end-point errors were only due to the implementation of an underscaled movement gain (15%), without direction bias. Interestingly, the level of undershoot was found to increase with the severity of the disease (inferred from the Unified Parkinson's Disease Rating Scale, UPDRS, motor score). We also observed that movement variability was amplified (32%), but only along the main movement axis (extent variability). Direction variability was not significantly different in the patient population and the control group. When considered together, these results support the idea that the basal ganglia are specifically involved in the control of movement amplitude (or of some covariates). We propose that this structure participates in extent planning by modulating cortical activity and/or the tuning of the spinal interneuronal circuits.

Neuroleptic malignant syndrome-like, or--dopaminergic malignant syndrome--due to levodopa therapy withdrawal. Clinical features in 11 patients

A clinical picture named neuroleptic malignant-like syndrome has been described in patients with Parkinson's disease (PD) who suddenly stop their L-dopa treatment. The sudden withdrawal of the drug is deemed to lead to an acute deficiency stage in a patient who has an iatrogenic increase of dopaminergic transmission. We present a series of 11 patients with PD with an average age of 72.09 years, a mean disease duration of 9.45 years who developed this problem after a 92.72 h latency period. If patients with PD develop severe rigidity, stupor and hyperthermia, L-dopa withdrawal should be suspected and the dopaminergic drug restarted as soon as possible.