Effects of pallidotomy and levodopa on walking and reaching movements in Parkinson's disease

The effect of dopaminergic treatment on whole body kinematics explored through network theory

Three-dimensional motion analysis represents a quantitative approach to assess spatio-temporal and kinematic changes in health and disease. However, these parameters provide only segmental information, discarding minor changes of complex whole body kinematics characterizing physiological and/or pathological conditions. We aimed to assess how levodopa intake affects the whole body, analyzing the kinematic interactions during gait in Parkinson's disease (PD) through network theory which assess the relationships between elements of a system. To this end, we analysed gait data of 23 people with PD applying network theory to the acceleration kinematic data of 21 markers placed on participants' body landmarks. We obtained a matrix of kinematic interactions (i.e., the kinectome) for each participant, before and after the levodopa intake, we performed a topological analysis to evaluate the large-scale interactions among body elements, and a multilinear regression analysis to verify whether the kinectome's topology could predict the clinical variations induced by levodopa. We found that, following levodopa intake, patients with PD showed less trunk and head synchronization (p-head = 0.048; p-7th cervical vertebrae = 0.032; p-10th thoracic vertebrae = 0.006) and an improved upper-lower limbs synchronization (elbows right, p = 0.002; left, p = 0.005), (wrists right, p = 0.003; left, p = 0.002; knees right, p = 0.003; left, p = 0.039) proportional to the UPDRS-III scores. These results may be attributable to the reduction of rigidity, following pharmacological treatment.

Revisiting the "Paradox of Stereotaxic Surgery": Insights Into Basal Ganglia-Thalamic Interactions

Basal ganglia dysfunction is implicated in movement disorders including Parkinson Disease, dystonia, and choreiform disorders. Contradicting standard "rate models" of basal ganglia-thalamic interactions, internal pallidotomy improves both hypo- and hyper-kinetic movement disorders. This "paradox of stereotaxic surgery" was recognized shortly after rate models were developed, and is underscored by the outcomes of deep brain stimulation (DBS) for movement disorders. Despite strong evidence that DBS activates local axons, the clinical effects of lesions and DBS are nearly identical. These observations argue against standard models in which GABAergic basal ganglia output gates thalamic activity, and raise the question of how lesions and stimulation can have similar effects. These paradoxes may be resolved by considering thalamocortical loops as primary drivers of motor output. Rather than suppressing or releasing cortex via motor thalamus, the basal ganglia may modulate the timing of thalamic perturbations to cortical activity. Motor cortex exhibits rotational dynamics during movement, allowing the same thalamocortical perturbation to affect motor output differently depending on its timing with respect to the rotational cycle. We review classic and recent studies of basal ganglia, thalamic, and cortical physiology to propose a revised model of basal ganglia-thalamocortical function with implications for basic physiology and neuromodulation.

Distinct Populations of Motor Thalamic Neurons Encode Action Initiation, Action Selection, and Movement Vigor

Motor thalamus (Mthal) comprises the ventral anterior, ventral lateral, and ventral medial thalamic nuclei in rodents. This subcortical hub receives input from the basal ganglia (BG), cerebellum, and reticular thalamus in addition to connecting reciprocally with motor cortical regions. Despite the central location of Mthal, the mechanisms by which it influences movement remain unclear. To determine its role in generating ballistic, goal-directed movement, we recorded single-unit Mthal activity as male rats performed a two-alternative forced-choice task. A large population of Mthal neurons increased their firing briefly near movement initiation and could be segregated into functional groups based on their behavioral correlates. The activity of "initiation" units was more tightly locked to instructional cues than movement onset, did not predict which direction the rat would move, and was anticorrelated with reaction time (RT). Conversely, the activity of "execution" units was more tightly locked to movement onset than instructional cues, predicted which direction the rat would move, and was anticorrelated with both RT and movement time. These results suggest that Mthal influences choice RT performance in two stages: short latency, nonspecific action initiation followed by action selection/invigoration. We discuss the implications of these results for models of motor control incorporating BG and cerebellar circuits.SIGNIFICANCE STATEMENT Motor thalamus (Mthal) is a central node linking subcortical and cortical motor circuits, though its precise role in motor control is unclear. Here, we define distinct populations of Mthal neurons that either encode movement initiation, or both action selection and movement vigor. These results have important implications for understanding how basal ganglia, cerebellar, and motor cortical signals are integrated. Such an understanding is critical to defining the pathophysiology of a range of BG- and cerebellum-linked movement disorders, as well as refining pharmacologic and neuromodulatory approaches to their treatment.

Neuromodulatory procedures for gait disorders in Parkinson's disease

The neurophysiology of gait is complex and involves numerous structures in the central nervous system. Gait disorders occur frequently in Parkinson's disease (PD), and their management may become cumbersome, especially in the more advanced stages. Neuromodulatory treatments, including deep brain stimulation, cortical stimulation and spinal cord stimulation, are reviewed with respect to their effectiveness to improve gait in PD patients. Although positive effects have been reported for all of these procedures, many issues remain in view of methodological heterogeneity, variability in outcome measures and sample size. Gait in PD remains a difficult issue with a tremendous impact on quality of life, for which future research is badly needed.

Characteristics of the sequence effect in Parkinson's disease

The sequence effect (SE) in Parkinson's disease (PD) is progressive slowing of sequential movements. It is a feature of bradykinesia, but is separate from a general slowness without deterioration over time. It is commonly seen in PD, but its physiology is unclear. We measured general slowness and the SE separately with a computer-based, modified Purdue pegboard in 11 patients with advanced PD. We conducted a placebo-controlled, four-way crossover study to learn whether levodopa and repetitive transcranial magnetic stimulation (rTMS) could improve general slowness or the SE. We also examined the correlation between the SE and clinical fatigue. Levodopa alone and rTMS alone improved general slowness, but rTMS showed no additive effect on levodopa. Levodopa alone, rTMS alone, and their combination did not alleviate the SE. There was no correlation between the SE and fatigue. This study suggests that dopaminergic dysfunction and abnormal motor cortex excitability are not the relevant mechanisms for the SE. Additionally, the SE is not a component of clinical fatigue. Further work is needed to establish the physiology and clinical relevance of the SE. © 2010 Movement Disorder Society.

Basal ganglia contributions to motor control: a vigorous tutor

The roles of the basal ganglia (BG) in motor control are much debated. Many influential hypotheses have grown from studies in which output signals of the BG were not blocked, but pathologically disturbed. A weakness of that approach is that the resulting behavioral impairments reflect degraded function of the BG per se mixed together with secondary dysfunctions of BG-recipient brain areas. To overcome that limitation, several studies have focused on the main skeletomotor output region of the BG, the globus pallidus internus (GPi). Using single-cell recording and inactivation protocols these studies provide consistent support for two hypotheses: the BG modulates movement performance ('vigor') according to motivational factors (i.e. context-specific cost/reward functions) and the BG contributes to motor learning. Results from these studies also add to the problems that confront theories positing that the BG selects movement, inhibits unwanted motor responses, corrects errors on-line, or stores and produces well-learned motor skills.

Motor sequences and the basal ganglia: kinematics, not habits

Despite a lack of definitive evidence, it is frequently proposed that the basal ganglia (BG) motor circuit plays a critical role in the storage and execution of movement sequences (or motor habits). To test this hypothesis directly, we inactivated the sensorimotor territory of the globus pallidus internus (sGPi, the main BG motor output) in two monkeys trained to perform overlearned and random sequences of four out-and-back reaching movements directed to visual targets. Infusion of muscimol (a GABA(A) agonist) into sGPi caused dysmetria and slowing of individual movements, but these impairments were virtually identical for overlearned and random sequences. The fluid predictive execution of learned sequences and the animals' tendency to reproduce the sequence pattern in random trials was preserved following pallidal blockade. These results suggest that the BG motor circuit contributes to motor execution, but not to motor sequencing or the storage of overlearned serial skills.

Analysis of spatial temporal plantar pressure pattern during gait in Parkinson's disease

Spatial temporal plantar pressure patterns measured with sheet-shaped pressure sensor were investigated to extract features of gait in Parkinson's disease. Both six subjects of Parkinson's disease (PD) and elderly fourteen normal control subjects were asked to execute usual walking on the pressure sensor sheets. Candidate features were step length, step time, gait velocity and transition of center of pressure to foot axis direction. The step length and gait velocity were smaller in PD subjects than those in normal subjects. Time of step cycle in three PD subjects were longer than that in normal subjects while the times of other PD subjects were similar to those of control subjects. The length from heel contact to toe off within one footprint was small in the subjects with short step length. Such possibility was indicated that Parkinson's disease in gait could be separated from normal subjects by these features.

Testing basal ganglia motor functions through reversible inactivations in the posterior internal globus pallidus

To test current hypotheses on the contribution of the basal ganglia (BG) to motor control, we examined the effects of muscimol-induced inactivations in the skeletomotor region of the internal globus pallidus (sGPi) on visually directed reaching. Injections were made in two monkeys trained to perform four out-and-back reaching movements in quick succession toward four randomly selected target locations. Following sGPi inactivations the following occurred. 1) Peak velocity and acceleration were decreased in nearly all sessions, whereas movement duration lengthened inconsistently. 2) Reaction times were unaffected on average, although minor changes were observed in several individual sessions. 3) Outward reaches showed a substantial hypometria that correlated closely with bradykinesia, but directional accuracy was unaffected. 4) Endpoint accuracy was preserved for the slow visually guided return movements. 5) No impairments were found in the rapid chaining of out-and-back movements, in the selection or initiation of four independent reaches in quick succession or in the quick on-line correction of initially misdirected reaches. 6) Inactivation-induced reductions in the magnitude of movement-related muscle activity (EMG) correlated with the severity of slowing and hypometria. There was no evidence for inactivation-induced alterations in the relative timing of EMG bursts, excessive cocontraction, or impaired suppression of antagonist EMG. Therefore disconnecting the BG motor pathway consistently produced bradykinesia and hypometria, but seldom affected movement initiation time, feedback-mediated guidance, the capacity to produce iterative reaches, or the ability to abruptly reverse movement direction. These results are discussed with reference to the idea that the BG motor loop may regulate energetic expenditures during movement (i.e., movement "vigor").

Parkinsonian deficits in context-dependent regulation of standing postural control

This study explored whether patients with Parkinson's disease alter the regulation of upright standing according to constraints imposed by the environmental context. The provision of context-dependent adaptations was inferred from the presence of adjustments to standing postural control that would serve to reduce fall risk when balance was challenged by a threatening environmental context. Participants were asked to stand as still as possible in two environmental context conditions that differed in the level of imposed postural threat: LOW threat and HIGH threat. Eight levodopa dependent patients with Parkinson's disease (PD) and eight age-matched control subjects (CTRL) provided the subject sample. PD patients were tested following a 12-h withdrawal of anti-Parkinsonian medications and approximately 1h post-medication. The CTRL group showed altered postural control in the HIGH threat condition, in a manner that was indicative of appropriate context-dependent regulation of standing. PD patients, in the non-medicated or medicated states, did not modify stance regulation when the environmental context heightened postural threat. Our results extend the current understanding of Parkinsonian deficits in the context-dependent regulation of postural control to include upright standing.

Pallidal deep brain stimulation and L-dopa do not improve qualitative aspects of skilled reaching in Parkinson's disease

OBJECTIVE

To determine effects of dopaminergic medication and pallidal deep brain stimulation (DBS) on skilled reach in Parkinson's disease (PD).

BACKGROUND

PD is a neurodegenerative disorder affecting motor control. While speed and execution of movements are improved by L-dopa, not all motor symptoms are alleviated. Little is known about the effects of DBS or medication on reaching.

DESIGN METHOD

Eight PD patients with unilateral pallidal DBS reached with the contra-lateral hand for a piece of food, placing it in the mouth, and returning to starting position. Testing was performed on no treatment, medication only, DBS only, and combined treatment. Reaches were digitally recorded and analyzed on a 21 point scale adapted from Eshkol-Wachman Notation. Analysis was blinded, with patients compared to age-matched controls.

RESULTS

Patients were tested 6-13 months after surgery. All showed significant improvement clinically and in UPDRS (III) scores. The following data were obtained on the reaching scale: normal controls 16.5-21.0 (mean 18.3), no treatment 3.0-12.5 (mean 7.4), medication only 7.0-14.0 (mean 10.3), DBS only 4.5-16.0 (mean 9.2), combined treatment 4.0-15.0 (mean 9.5). The difference between controls and all treatment groups was statistically significant (P<0.005). All aspects of reach were compromised. No significant differences were found among the four conditions.

CONCLUSIONS

This study is consistent with accumulating evidence that some aspects of motor performance in PD patients, such as reaching, are resistant to L-dopa. Also, pallidal DBS does not improve those parameters that are resistant to L-dopa, either alone or in combination with medication.

Falls in Parkinson's disease

PURPOSE OF REVIEW

To summarize the latest insights into the clinical significance, assessment, pathophysiology and treatment of falls in Parkinson's disease.

RECENT FINDINGS

Recent studies have shown that falls are common in Parkinson's disease, even when compared with other fall-prone populations. The clinical impact of falls is considerable, often leading to an incapacitating fear of renewed falls. The associated costs for society are substantial. Clinical assessment often includes the retropulsion test, and recent studies have offered practical recommendations regarding the execution and scoring of this test. Insights into the pathophysiology underlying falls are growing and point to an important role for the loss of inter-segmental flexibility ('stiffness'), which predisposes patients to falls in a backward or medial-lateral direction. New evidence has clarified why Parkinson's disease patients commonly fall during transfers and under 'dual tasking' circumstances. The absence of adequately directed arm movements may explain the relatively high proportion of hip fractures in Parkinson's disease. The importance of freezing of gait as a cause of falls is recognized, and we are beginning to understand the different manifestations of gait freezing. Recent work has defined the contributions of pharmacotherapy, stereotactic neurosurgery, physiotherapy and multidisciplinary interventions in the treatment of postural instability to prevent falls in Parkinson's disease.

SUMMARY

No dramatic breakthroughs have occurred during the review period, but new information in various areas may be useful for practising clinicians. Interesting new questions have been raised that should fuel studies of pathophysiological mechanisms, which could help in the development of improved treatment strategies to reduce falls in Parkinson's disease.