Defective inhibition and inter-regional phase synchronization in pianists with musician's dystonia: an EEG study

Task-related brain activity in upper limb dystonia revealed by simultaneous fNIRS and EEG

OBJECTIVE

The aim of this study was to explore differences in brain activity and connectivity using simultaneous electroencephalography and near-infrared spectroscopy in patients with focal dystonia during handwriting and finger-tapping tasks.

METHODS

Patients with idiopathic right upper limb focal dystonia and controls were assessed by simultaneous near-infrared spectroscopy and electroencephalography during the writing and finger-tapping tasks in terms of the mu-alpha, mu-beta, beta and low gamma power and effective connectivity, as well as relative changes in oxyhemoglobin (oxy-Hb) and deoxyhemoglobin using a channel-wise approach with a mixed-effect model.

RESULTS

Patients exhibited higher oxy-Hb levels in the right and left motor cortex and supplementary motor area during writing, but lower oxy-Hb levels in the left sensorimotor and bilateral somatosensory area during finger-tapping compared to controls. During writing, patients showed increased low gamma power in the bilateral sensorimotor cortex and less mu-beta and beta attenuation compared to controls. Additionally, patients had reduced connectivity between the supplementary motor area and the left sensorimotor cortex during writing. No differences were observed in terms of effective connectivity in either task. Finally, patients failed to attenuate the mu-alpha, mu-beta, and beta rhythms during the finger-tapping task.

CONCLUSIONS

Cortical blood flow and EEG spectral power differ between controls and dystonia patients, depending on the task. Writing increased blood flow and altered connectivity in dystonia patients, and it also decreased slow-band attenuation. Finger-tapping decreased blood flow and slow-band attenuation.

SIGNIFICANCE

Simultaneous fNIRS and EEG may show relevant information regarding brain dynamics in movement disorders patients in unconstrained environments.

Brain network flexibility as a predictor of skilled musical performance

Interactions between the body and the environment are dynamically modulated by upcoming sensory information and motor execution. To adapt to this behavioral state-shift, brain activity must also be flexible and possess a large repertoire of brain networks so as to switch them flexibly. Recently, flexible internal brain communications, i.e. brain network flexibility, have come to be recognized as playing a vital role in integrating various sensorimotor information. Therefore, brain network flexibility is one of the key factors that define sensorimotor skill. However, little is known about how flexible communications within the brain characterize the interindividual variation of sensorimotor skill and trial-by-trial variability within individuals. To address this, we recruited skilled musical performers and used a novel approach that combined multichannel-scalp electroencephalography, behavioral measurements of musical performance, and mathematical approaches to extract brain network flexibility. We found that brain network flexibility immediately before initiating the musical performance predicted interindividual differences in the precision of tone timbre when required for feedback control, but not for feedforward control. Furthermore, brain network flexibility in broad cortical regions predicted skilled musical performance. Our results provide novel evidence that brain network flexibility plays an important role in building skilled sensorimotor performance.

Temporal Signature of Task-Specificity in Isolated Focal Laryngeal Dystonia

BACKGROUND AND OBJECTIVE

Laryngeal dystonia (LD) is focal task-specific dystonia, predominantly affecting speech but not whispering or emotional vocalizations. Prior neuroimaging studies identified brain regions forming a dystonic neural network and contributing to LD pathophysiology. However, the underlying temporal dynamics of these alterations and their contribution to the task-specificity of LD remain largely unknown. The objective of the study was to identify the temporal-spatial signature of altered cortical oscillations associated with LD pathophysiology.

METHODS

We used high-density 128-electrode electroencephalography (EEG) recordings during symptomatic speaking and two asymptomatic tasks, whispering and writing, in 24 LD patients and 22 healthy individuals to investigate the spectral dynamics, spatial localization, and interregional effective connectivity of aberrant cortical oscillations within the dystonic neural network, as well as their relationship with LD symptomatology.

RESULTS

Symptomatic speaking in LD patients was characterized by significantly increased gamma synchronization in the middle/superior frontal gyri, primary somatosensory cortex, and superior parietal lobule, establishing the altered prefrontal-parietal loop. Hyperfunctional connectivity from the left middle frontal gyrus to the right superior parietal lobule was significantly correlated with the age of onset and the duration of LD symptoms. Asymptomatic whisper in LD patients had not no statistically significant changes in any frequency band, whereas asymptomatic writing was characterized by significantly decreased synchronization of beta-band power localized in the right superior frontal gyrus.

CONCLUSION

Task-specific oscillatory activity of prefrontal-parietal circuitry is likely one of the underlying mechanisms of aberrant heteromodal integration of information processing and transfer within the neural network leading to dystonic motor output. © 2023 International Parkinson and Movement Disorder Society.

The Technical Ability and Performing Scale (TAPS): A newly developed patient-reported functional rating scale for Musician's focal dystonia

BACKGROUND

Musician's Focal Dystonia (MFD) is the most common adult-onset dystonia involving the hand and can cause a professional music career to end. MFD affects about 1% of professional musicians and is a challenging clinical condition to treat. This work aimed to validate the Technical Ability and Performing Scale (TAPS), a newly-developed patient-reported functional rating scale for the clinical assessment of the MFD burden.

METHODS

Seventy-seven musicians with MFD (40.84 ± 13.14 years) who accessed "Sol Diesis Service" were consecutively enrolled. Each subject filled in the TAPS after playing six technical passages of different complexity for 45 s each. The clinicians also collected the Arm Dystonia Disability Scale (ADDS) and Tubiana-Chamagne Scale (TCS). Cronbach's α coefficient was used to assess reliability; concurrent validity was measured using correlation with validated tools (ADDS and TCS).

RESULTS

Our results showed that the symptoms of dystonia appeared at around 33 years of age and lasted for at least three years. The Cronbach's α displayed good internal consistency (0.817) for Technical Ability (TA). The two TAPS scores, TA and Performing Score (PS), positively correlated with TCS total score and negatively with ADDS total score (concurrent validity).

CONCLUSIONS

The TAPS is a reliable and valid tool for the clinical assessment of the MFD burden. This patient-reported outcome measure may facilitate patient engagement in decision-making about their care and can help healthcare professionals to monitor the musician's change during the rehabilitative intervention.

Electrophysiological Signature and the Prediction of Deep Brain Stimulation Withdrawal and Insertion Effects

Deep brain stimulation (DBS) serves as a treatment for neurological and psychiatric disorders, such as Parkinson's disease (PD), essential tremor, dystonia, Tourette Syndrome (GTS), Huntington's disease, and obsessive-compulsive disorder (OCD). There is broad experience with the short-term effects of DBS in individual diseases and their signs/symptoms. However, even in acute treatment and for the same disorder or a given disorder, a prediction of effect is not perfect. Even further, the factors that influence the long-term effect of DBS and its withdrawal are hardly characterized. In this work, we aim to shed light on an important topic, the question of “DBS dependency.” To address this, we make use of the Kuramoto model of phase synchronization (oscillation feature) endowed with neuroplasticity to study the effects of DBS under successive withdrawals and renewals of neuromodulation as well as influence of treatment duration in de novo DBS “patients.” The results of our simulation show that the characteristics of neuroplasticity have a profound effect on the stability and mutability of oscillation synchronization patterns across successive withdrawal and renewal of DBS in chronic “patients” and also in de novo DBS “patients” with varying duration of treatment (here referred to as the “number of iterations”). Importantly, the results demonstrate the strong effect of the individual neuroplasticity makeup on the behavior of synchrony of oscillatory activity that promotes certain disorder/disease states or symptoms. The effect of DBS-mediated neuromodulation and withdrawal is highly dependent on the makeup of the neuroplastic signature of a disorder or an individual.

Testing rTMS-Induced Neuroplasticity: A Single Case Study of Focal Hand Dystonia

Focal hand dystonia in musicians is a neurological motor disorder in which aberrant plasticity is caused by excessive repetitive use. This work's purposes were to induce plasticity changes in a dystonic musician through five daily thirty-minute sessions of 1 Hz repetitive transcranial magnetic stimulation (rTMS) applied to the left M1 by using neuronavigated stimulation and to reliably measure the effect of these changes. To this aim, the relationship between neuroplasticity changes and motor recovery was investigated using fine-grained kinematic analysis. Our results suggest a statistically significant improvement in motor coordination both in a task resembling the dystonic-inducing symptoms and in a reach-to-grasp task. This single case study supports the safe and effective use of noninvasive brain stimulation in neurologic patients and highlights the importance of evaluating outcomes in measurable ways. This issue is a key aspect to focus on to classify the clinical expression of dystonia. These preliminary results promote the adoption of kinematic analysis as a valuable diagnostic tool.

Ready for change: Oscillatory mechanisms of proactive motor control

Proactive motor control is a preparatory mechanism facilitating upcoming action inhibition or adaptation. Previous studies investigating proactive motor control mostly focused on response inhibition, as in the classical go-nogo or stop-signal tasks. However, everyday life rarely calls for the complete suppression of actions without subsequent behavioral adjustment. Therefore, we conducted a modified cued go-nogo-change task, in which cues indicated whether participants might have to change to an alternative action or inhibit the response to an upcoming target. Based on the dual-mechanisms of control framework and using electroencephalography (EEG), we investigated the role of the sensorimotor cortex and of prefrontal regions in preparing to change and cancel motor responses. We focused on mu and beta power over sensorimotor cortex ipsi- and contralateral to an automatic motor response and on prefrontal beta power. Over ipsilateral sensorimotor cortex, mu and beta power was relatively decreased when anticipating to change or inhibit the automatic motor behavior. Moreover, alpha phase coupling between ipsilateral motor cortex and prefrontal areas decreased when preparing to change, suggesting a decoupling of sensorimotor regions from prefrontal control. When the standard motor action actually had to be changed, prefrontal beta power increased, reflecting enhanced cognitive control. Our data highlight the role of the ipsilateral motor cortex in preparing to inhibit and change upcoming motor actions. Here, especially mu power and phase coupling seem to be critical to guide upcoming behavior.

Isolated Focal Dystonia as a Disorder of Large-Scale Functional Networks

Isolated focal dystonias are a group of disorders with diverse symptomatology but unknown pathophysiology. Although recent neuroimaging studies demonstrated regional changes in brain connectivity, it remains unclear whether focal dystonia may be considered a disorder of abnormal networks. We examined topology as well as the global and local features of large-scale functional brain networks across different forms of isolated focal dystonia, including patients with task-specific (TSD) and nontask-specific (NTSD) dystonias. Compared with healthy participants, all patients showed altered network architecture characterized by abnormal expansion or shrinkage of neural communities, such as breakdown of basal ganglia-cerebellar community, loss of a pivotal region of information transfer (hub) in the premotor cortex, and pronounced connectivity reduction within the sensorimotor and frontoparietal regions. TSD were further characterized by significant connectivity changes in the primary sensorimotor and inferior parietal cortices and abnormal hub formation in insula and superior temporal cortex, whereas NTSD exhibited abnormal strength and number of regional connections. We suggest that isolated focal dystonias likely represent a disorder of large-scale functional networks, where abnormal regional interactions contribute to network-wide functional alterations and may underline the pathophysiology of isolated focal dystonia. Distinct symptomatology in TSD and NTSD may be linked to disorder-specific network aberrations.

Sensory feedback - Dependent neural de-orchestration: The effect of altered sensory feedback on Musician's Dystonia

PURPOSE

Musician's dystonia (MD) is a task-specific movement disorder related to extensive expert music performance training. Similar to other forms of focal dystonia, MD involves sensory deficits and abnormal patterns of sensorimotor integration. The present study investigated the impaired cortical sensorimotor network of pianists who suffer from MD by employing altered auditory and tactile feedback during scale playing with multichannel EEG.

METHODS

9 healthy professional pianists and 9 professional pianists suffering from right hand MD participated in an experiment that required repeated scale playing on a MIDI piano under altered sensory feedback while EEG was measured.

RESULTS

The comparison of EEG data in healthy pianists and pianists suffering from MD revealed a higher degree of inter-regional phase synchronisation between the frontal and parietal regions and between the temporal and central regions in the patient group and in conditions that are relevant to the long-trained auditory-motor coupling (normal auditory feedback and complete deprivation of auditory feedback), but such abnormalities decreased in conditions with delayed auditory feedback and altered tactile feedback.

CONCLUSIONS

These findings support the hypothesis that the impaired sensorimotor integration of MD patients is specific to the type of overtrained task that the patients were trained for and can be modified with altered sensory feedback.

Abnormal movement preparation in task-specific focal hand dystonia

Electrophysiological and behavioral studies in primary dystonia suggest abnormalities during movement preparation, but this crucial phase preceding movement onset has not yet been studied specifically with functional magnetic resonance imaging (fMRI). To identify abnormalities in brain activation during movement preparation, we used event-related fMRI to analyze behaviorally unimpaired sequential finger movements in 18 patients with task-specific focal hand dystonia (FHD) and 18 healthy subjects. Patients and controls executed self-initiated or externally cued prelearnt four-digit sequential movements using either right or left hands. In FHD patients, motor performance of the sequential finger task was not associated with task-related dystonic posturing and their activation levels during motor execution were highly comparable with controls. On the other hand reduced activation was observed during movement preparation in the FHD patients in left premotor cortex / precentral gyrus for all conditions, and for self-initiation additionally in supplementary motor area, left mid-insula and anterior putamen, independent of effector side. Findings argue for abnormalities of early stages of motor control in FHD, manifesting during movement preparation. Since deficits map to regions involved in the coding of motor programs, we propose that task-specific dystonia is characterized by abnormalities during recruitment of motor programs: these do not manifest at the behavioral level during simple automated movements, however, errors in motor programs of complex movements established by extensive practice (a core feature of FHD), trigger the inappropriate movement patterns observed in task-specific dystonia.

Complex-value coherence mapping reveals novel abnormal resting-state functional connectivity networks in task-specific focal hand dystonia

Resting-state imaging designs are powerful in modeling functional networks in movement disorders because they eliminate task performance related confounds. However, the most common metric for quantifying functional connectivity, i.e., bivariate magnitude coherence (Coh), can sometimes be contaminated by spurious correlations in blood-oxygen level dependent (BOLD) signal due to smoothing and seed blur, thereby limiting the identification of true interactions between neighboring neural populations. Here, we apply a novel functional connectivity metric., i.e., imaginary coherence (ICoh), to BOLD fMRI data in healthy individuals and patients with task-specific focal hand dystonia (tspFHD), in addition to the traditional magnitude Coh metric. We reconstructed resting-state sensorimotor, basal ganglia, and default-mode networks using both Coh and ICoh. We demonstrate that indeed the ICoh metric eliminates spatial blur around seed placement and reflects slightly different networks from Coh. We then identified significant reductions in resting-state connectivity within both the sensorimotor and basal ganglia networks in patients with tspFHD, primarily in the hemisphere contralateral to the affected hand. Collectively, these findings direct our attention to the fact that multiple networks are decoupled in tspFHD that can be unraveled by different functional connectivity metrics, and that this aberrant communication contributes to clinical deficits in the disorder.

Patterns of muscle activity for digital coarticulation

Although piano playing is a highly skilled task, basic features of motor pattern generation may be shared across tasks involving fine movements, such as handling coins, fingering food, or using a touch screen. The scripted and sequential nature of piano playing offered the opportunity to quantify the neuromuscular basis of coarticulation, i.e., the manner in which the muscle activation for one sequential element is altered to facilitate production of the preceding and subsequent elements. Ten pianists were asked to play selected pieces with the right hand at a uniform tempo. Key-press times were recorded along with the electromyographic (EMG) activity from seven channels: thumb flexor and abductor muscles, a flexor for each finger, and the four-finger extensor muscle. For the thumb and index finger, principal components of EMG waveforms revealed highly consistent variations in the shape of the flexor bursts, depending on the type of sequence in which a particular central key press was embedded. For all digits, the duration of the central EMG burst scaled, along with slight variations across subjects in the duration of the interkeystroke intervals. Even within a narrow time frame (about 100 ms) centered on the central EMG burst, the exact balance of EMG amplitudes across multiple muscles depended on the nature of the preceding and subsequent key presses. This fails to support the idea of fixed burst patterns executed in sequential phases and instead provides evidence for neuromuscular coarticulation throughout the time course of a hand movement sequence.

Functional MRI study of response inhibition in myoclonus dystonia

BACKGROUND

Myoclonus-dystonia (MD) is a movement disorder characterized by myoclonic jerks, dystonic postures and psychiatric co-morbidity. A mutation in the DYT11 gene underlies half of MD cases. We hypothesize that MD results from a dysfunctional basal ganglia network causing insufficient inhibitory motor control. To test this hypothesis functional MRI (fMRI) was performed using a validated "Go/No go" task, in order to localize blood-oxygen-level dependence (BOLD) effects corresponding to Response Inhibition (RI).

METHODS

Twenty-four MD patients (fifteen DYT11 positive) and 24 matched controls responded with a button press to Go (Go-Response) or No go (referred to as 'Stop') cues, resulting in analyses of accurate response suppression to Stop cues (Stop-Inhibit), and incorrect responses to Go cues (Go-Inhibit), or to Stop cues (Stop-Response).

RESULTS

Response accuracy in patients was impaired due to frequent Go-Inhibit errors. Image analysis of the Stop-Inhibit contrast demonstrated frontal, caudate and cingular activity in both groups. Compared to controls, MD patients showed increased primary motor cortex and insular activation. During Go-Inhibit trials, patients revealed increased activity in the contralateral thalamus (ventral lateral nucleus) and dorso-lateral-prefrontal cortex. In a post-hoc analysis comparing MD patients, DYT11 positive patients demonstrated anterior cerebellum hyperactivation on all contrasts and increased putaminal activation in the Stop-Response contrast.

CONCLUSIONS

This study demonstrates a distinct association of motor symptoms in MD with the ventral lateral nucleus of the thalamus. Cerebellar dysfunction distinguishes DYT11 positive from negative patients. We suggest that MD might be best considered as a disorder of the cortico-ponto-cerebello-thalamo-cortical system.

Aberrant Oscillatory Activity during Simple Movement in Task-Specific Focal Hand Dystonia

In task-specific focal hand dystonia (tspFHD), the temporal dynamics of cortical activity in the motor system and how these processes are related to impairments in sensory and motor function are poorly understood. Here, we use time-frequency reconstructions of magnetoencephalographic (MEG) data to elaborate the temporal and spatial characteristics of cortical activity during movement. A self-paced finger tapping task during MEG recording was performed by 11 patients with tspFHD and 11 matched healthy controls. In both groups robust changes in beta (12-30 Hz) and high gamma (65-90 Hz) oscillatory activity were identified over sensory and motor cortices during button press. A significant decrease [p < 0.05, 1% False Discovery Rate (FDR) corrected] in high gamma power during movements of the affected hand was identified over ipsilateral sensorimotor cortex in the period prior to (-575 ms) and following (725 ms) button press. Furthermore, an increase (p < 0.05, 1% FDR corrected) in beta power suppression following movement of the affected hand was identified over visual cortex in patients with tspFHD. For movements of the unaffected hand, a significant (p < 0.05, 1% FDR corrected) increase in beta power suppression was identified over secondary somatosensory cortex (S2) in the period following button press in patients with tspFHD. Oscillatory activity within in the tspFHD group was however not correlated with clinical measures. Understanding these aberrant oscillatory dynamics can provide the groundwork for interventions that focus on modulating the timing of this activity.

Structural, functional and molecular imaging of the brain in primary focal dystonia--a review

Primary focal dystonias form a group of neurological disorders characterized by involuntary, sustained muscle contractions causing twisting movements and abnormal postures. The estimated incidence is 12-25 per 100,000. The pathophysiology is largely unclear but genetic and environmental influences are suspected. Over the last decade neuroimaging techniques have been applied in patients with focal dystonia. Using structural, functional and molecular imaging techniques, abnormalities have been detected mainly in the sensorimotor cortex, basal ganglia and cerebellum. The shared anatomical localisations in different forms of focal dystonia support the hypothesis of a common causative mechanism. The primary defect in focal dystonia is hypothesised in the motor circuit connecting the cortex, basal ganglia, and cerebellum. Imaging techniques have clearly enhanced current knowledge on the pathophysiology of primary focal dystonia and will continue to do so in the future.

EEG oscillatory patterns are associated with error prediction during music performance and are altered in musician's dystonia

Skilled performance requires the ability to monitor ongoing behavior, detect errors in advance and modify the performance accordingly. The acquisition of fast predictive mechanisms might be possible due to the extensive training characterizing expertise performance. Recent EEG studies on piano performance reported a negative event-related potential (ERP) triggered in the ACC 70 ms before performance errors (pitch errors due to incorrect keypress). This ERP component, termed pre-error related negativity (pre-ERN), was assumed to reflect processes of error detection in advance. However, some questions remained to be addressed: (i) Does the electrophysiological marker prior to errors reflect an error signal itself or is it related instead to the implementation of control mechanisms? (ii) Does the posterior frontomedial cortex (pFMC, including ACC) interact with other brain regions to implement control adjustments following motor prediction of an upcoming error? (iii) Can we gain insight into the electrophysiological correlates of error prediction and control by assessing the local neuronal synchronization and phase interaction among neuronal populations? (iv) Finally, are error detection and control mechanisms defective in pianists with musician's dystonia (MD), a focal task-specific dystonia resulting from dysfunction of the basal ganglia-thalamic-frontal circuits? Consequently, we investigated the EEG oscillatory and phase synchronization correlates of error detection and control during piano performances in healthy pianists and in a group of pianists with MD. In healthy pianists, the main outcomes were increased pre-error theta and beta band oscillations over the pFMC and 13-15 Hz phase synchronization, between the pFMC and the right lateral prefrontal cortex, which predicted corrective mechanisms. In MD patients, the pattern of phase synchronization appeared in a different frequency band (6-8 Hz) and correlated with the severity of the disorder. The present findings shed new light on the neural mechanisms, which might implement motor prediction by means of forward control processes, as they function in healthy pianists and in their altered form in patients with MD.

Focal dystonia in musicians

INTRODUCTION

A special group of focal dystonia is that known as occupational, which include dystonic disorders triggered by repetitive motor activity, closely associated with the professional activity of a specific task that the affected person performs. In this sense, musicians are a population particularly vulnerable to this disorder, which is presented during the execution of highly trained movements.

OBJECTIVE

This article reviews the pathophysiology of focal dystonia and its therapeutic implications.

DEVELOPMENT

The pathophysiological basis of focal dystonia in the musician is still not well established. However, due to the contribution of neurophysiological studies and functional neuroimaging, there is growing evidence of anomalies in the processing of sensory information, sensory-motor integration, cortical and subcortical inhibitory processes, which underline this disease. Clinically, it is characterised by the appearance of involuntary muscle contractions, and is associated with loss of motor control while practicing music. It is a gradual appearance and sometimes there may be a history of musculoskeletal injuries or non-physiological postures preceding the appearance of the symptoms. The neurological examination is usually normal, although subtle dystonic postures can develop spontaneously or with movements that involve the affected segments. The dystonia remains focal and is not generalised.

CONCLUSIONS

Treatment is based on using multiple strategies for the management of the dystonia, with variable results. Although a specific therapy has not been defined, there are general principles that are combined in each situation looking for results. This includes, among others, pharmacological interventions, management with botulinum toxin, and sensory re-training techniques.

Focal dystonia in musicians: phenomenology, pathophysiology and triggering factors

BACKGROUND

Musician's dystonia is a task-specific movement disorder that manifests itself as a loss of voluntary motor control in extensively trained movements. In many cases, the disorder terminates the careers of affected musicians. Approximately, 1% of all professional musicians are affected. The pathophysiology of the disorder is still unclear. Findings include: (i) reduced inhibition in different levels of the central nervous system, (ii) maladaptive plasticity, e.g. in the somatosensory cortex and in the basal ganglia and (iii) alterations in sensorimotor processing.

METHODS

Review of the literature.

RESULTS

Epidemiological data demonstrated a higher risk for those musicians who play instruments requiring maximal fine-motor skills. For instruments where workload differs across hands, focal dystonia appears more often in the more intensely used hand. In psychological studies, musicians with dystonia had more perfectionist tendencies than healthy musicians. These findings strengthen the assumption that behavioural factors may be involved in the etiology of musician's dystonia. Hereditary factors may play a greater role than previously assumed.

CONCLUSIONS

We propose a heuristic model that may explain the relatively high incidence of focal dystonia in musicians. This model assumes the coactions between a predominantly genetically determined predisposition and intrinsic and extrinsic triggering factors.