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Evers S, Brameyer H, Pogatzki-Zahn E. The Impact of Music Perception on Quantitative Sensory Testing (QST). J Clin Med 2024; 13:2471. [PMID: 38731000 PMCID: PMC11084946 DOI: 10.3390/jcm13092471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Objective: The impact of listening to music on pain perception has been evaluated using questionnaires and numeric/visual analogue scales. In this study, the impact of music perception on sensory pain functions was measured by means of quantitative sensory testing. Methods: We enrolled 10 female and 10 male healthy subjects (10 of them were professional musicians). All subjects underwent, in total, four quantitative sensory testing measures (first: baseline; second: after pleasant music [Johannes Brahms, 3rd symphony, 3rd movement]; third: after unpleasant music [Krzysztof Penderecki, Threnos]; fourth: after a longer break). The pleasantness of music was evaluated using the Ertel differential scale. Results: After the participants listened to pleasant music, an increased sensitivity to cold stimuli (both threshold and pain), to mechanical stimuli (only for threshold), and to repeated stimuli (wind-up reaction) was noted. Listening to unpleasant music was not associated with changes in sensitivity. We did not observe any significant differences between male and female subjects or between musicians and non-musicians. There was no significant correlation between the rating of the music as pleasant/unpleasant and the different quantitative sensory testing measures. Conclusions: Our data show that listening to music inducing a pleasant feeling can increase the sensitivity to stimuli applied during a quantitative sensory testing session. This should be considered when performing or interpreting quantitative sensory testing examinations. Interestingly, this finding is in contrast to the observation that listening to music can decrease pain perception during painful procedures.
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Affiliation(s)
- Stefan Evers
- Department of Neurology, University of Münster, 48149 Münster, Germany
- Department of Neurology, Krankenhaus Lindenbrunn, 31863 Coppenbrügge, Germany
| | - Henning Brameyer
- Department of Neurology, University of Münster, 48149 Münster, Germany
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2
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Wilkes BJ, Adury RZ, Berryman D, Concepcion LR, Liu Y, Yokoi F, Maugee C, Li Y, Vaillancourt DE. Cell-specific Dyt1 ∆GAG knock-in to basal ganglia and cerebellum reveal differential effects on motor behavior and sensorimotor network function. Exp Neurol 2023; 367:114471. [PMID: 37321386 PMCID: PMC10695146 DOI: 10.1016/j.expneurol.2023.114471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023]
Abstract
Dystonia is a neurological movement disorder characterized by repetitive, unintentional movements and disabling postures that result from sustained or intermittent muscle contractions. The basal ganglia and cerebellum have received substantial focus in studying DYT1 dystonia. It remains unclear how cell-specific ∆GAG mutation of torsinA within specific cells of the basal ganglia or cerebellum affects motor performance, somatosensory network connectivity, and microstructure. In order to achieve this goal, we generated two genetically modified mouse models: in model 1 we performed Dyt1 ∆GAG conditional knock-in (KI) in neurons that express dopamine-2 receptors (D2-KI), and in model 2 we performed Dyt1 ∆GAG conditional KI in Purkinje cells of the cerebellum (Pcp2-KI). In both of these models, we used functional magnetic resonance imaging (fMRI) to assess sensory-evoked brain activation and resting-state functional connectivity, and diffusion MRI to assess brain microstructure. We found that D2-KI mutant mice had motor deficits, abnormal sensory-evoked brain activation in the somatosensory cortex, as well as increased functional connectivity of the anterior medulla with cortex. In contrast, we found that Pcp2-KI mice had improved motor performance, reduced sensory-evoked brain activation in the striatum and midbrain, as well as reduced functional connectivity of the striatum with the anterior medulla. These findings suggest that (1) D2 cell-specific Dyt1 ∆GAG mediated torsinA dysfunction in the basal ganglia results in detrimental effects on the sensorimotor network and motor output, and (2) Purkinje cell-specific Dyt1 ∆GAG mediated torsinA dysfunction in the cerebellum results in compensatory changes in the sensorimotor network that protect against dystonia-like motor deficits.
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Affiliation(s)
- B J Wilkes
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA.
| | - R Z Adury
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - D Berryman
- Norman Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - L R Concepcion
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Y Liu
- Norman Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - F Yokoi
- Norman Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - C Maugee
- Norman Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Y Li
- Norman Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - D E Vaillancourt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Norman Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA; Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
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Improved acquisition of contact heat evoked potentials with increased heating ramp. Sci Rep 2022; 12:925. [PMID: 35042939 PMCID: PMC8766469 DOI: 10.1038/s41598-022-04867-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/29/2021] [Indexed: 12/05/2022] Open
Abstract
Contact heat evoked potentials (CHEPs) represent an objective and non-invasive measure to investigate the integrity of the nociceptive neuraxis. The clinical value of CHEPs is mostly reflected in improved diagnosis of peripheral neuropathies and spinal lesions. One of the limitations of conventional contact heat stimulation is the relatively slow heating ramp (70 °C/s). This is thought to create a problem of desynchronized evoked responses in the brain, particularly after stimulation in the feet. Recent technological advancements allow for an increased heating ramp of contact heat stimulation, however, to what extent these improve the acquisition of evoked potentials is still unknown. In the current study, 30 healthy subjects were stimulated with contact heat at the hand and foot with four different heating ramps (i.e., 150 °C/s, 200 °C/s, 250 °C/s, and 300 °C/s) to a peak temperature of 60 °C. We examined changes in amplitude, latency, and signal-to-noise ratio (SNR) of the vertex (N2-P2) waveforms. Faster heating ramps decreased CHEP latency for hand and foot stimulation (hand: F = 18.41, p < 0.001; foot: F = 4.19, p = 0.009). Following stimulation of the foot only, faster heating ramps increased SNR (F = 3.32, p = 0.024) and N2 amplitude (F = 4.38, p = 0.007). Our findings suggest that clinical applications of CHEPs should consider adopting faster heating ramps up to 250 °C/s. The improved acquisition of CHEPs might consequently reduce false negative results in clinical cohorts. From a physiological perspective, our results demonstrate the importance of peripherally synchronizing afferents recruitment to satisfactorily acquire CHEPs.
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Huang X, Lin J, Shang H, Yang J. Voxel-based meta-analysis of gray matter abnormalities in idiopathic dystonia. J Neurol 2022; 269:2862-2873. [PMID: 35013788 DOI: 10.1007/s00415-022-10961-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Neuroimaging studies have reported gray matter changes in patients with idiopathic dystonia but with considerable variations. Here, we aimed to investigate the convergence of dystonia-related gray matter changes across studies. METHODS The whole brain voxel-based morphometry studies comparing idiopathic dystonia and healthy controls were systematically searched in the PubMed, Web of Science and Embase. Meta-analysis of gray matter changes was performed using the anisotropic effect size-based signed differential mapping. RESULTS Twenty-eight studies comparing 701 idiopathic dystonia patients and 712 healthy controls were included in the meta-analysis. Compared to healthy controls, idiopathic dystonia patients showed increased gray matter in bilateral precentral and postcentral gyri, bilateral putamen and pallidum, right insula, and left supramarginal gyrus, while decreased gray matter in bilateral temporal poles, bilateral supplementary motor areas, right angular gyrus, inferior parietal gyrus and precuneus, left insula and inferior frontal gyrus. These findings remained robust in the jackknife sensitivity analysis, and no significant heterogeneity was detected. Subgroup analyses of different phenotypes of dystonia were performed to further confirm the above findings. CONCLUSION The meta-analysis showed that consistent widespread gray matter abnormalities were shared in different subtypes of idiopathic dystonia and were not restricted to the corticostriatal circuits.
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Affiliation(s)
- Xiang Huang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Junyu Lin
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huifang Shang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Yang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Pérez-de-Heredia-Torres M, García-Bravo C, Huertas-Hoyas E, Martínez-Piédrola MR, Serrada-Tejeda S, Martínez-Castrillo JC. Sensitivity and pain in focal dystonia of the hand. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:711-716. [PMID: 34801480 DOI: 10.1016/j.nrleng.2019.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 12/12/2019] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION A growing body of evidence highlights the importance of understanding both the sensory and the motor pathophysiology of focal dystonia in order to improve its treatment. This study aims to evaluate somatosensory afferences in patients with focal or segmental dystonia affecting the upper limbs, to analyse whether the dominant limb is more frequently affected, to analyse pain tolerance, and to examine the potential association with pain perception in patients with hand dystonia. METHODS We recruited 24 participants: 12 patients with focal hand dystonia and 12 individuals without dystonia. All participants were evaluated with a digital algometer (Somedic SenseLab AB®, Farsta, Sweden), a Semmes-Weinstein monofilament test, and the visual analogue scale for pain. RESULTS According to our data, patients showed greater impairment in surface sensitivity than controls, both in the dominant and the non-dominant hands, as well as greater presence of pain (P > .001). Furthermore, the dystonia group showed a negative correlation between perceived pain and pressure pain tolerance threshold (rho = -0.83; P < .001). CONCLUSIONS Patients with focal hand dystonia presented alterations in sensitivity and more severe perceived pain than individuals without dystonia. Future studies with larger samples should aim to analyse the clinical implications and everyday impact of both objective and subjective pain.
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Affiliation(s)
- M Pérez-de-Heredia-Torres
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - C García-Bravo
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - E Huertas-Hoyas
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
| | - M R Martínez-Piédrola
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - S Serrada-Tejeda
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
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Scuteri D, Rombolà L, Natoli S, Pisani A, Bonsi P, Hamamura K, Bagetta G, Tonin P, Corasaniti MT. Exploitation of Thermal Sensitivity and Hyperalgesia in a Mouse Model of Dystonia. Life (Basel) 2021; 11:life11090985. [PMID: 34575134 PMCID: PMC8468866 DOI: 10.3390/life11090985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 12/02/2022] Open
Abstract
Neuropathic pain is characterized by mechanical allodynia and thermal hyperalgesia to heat, and it affects some 20% of European population. Patients suffering from several neurologic diseases experience neuropathic pain, often finding no relief in therapy. Transgenic mice expressing the gene encoding the human mutant (hMT) or the human wild-type (hWT) torsin A represent a preclinical model of DYT1 dystonia which is the most common form of early-onset inherited dystonia. Baseline thermal sensitivity and hyperalgesia to heat have never been studied in models of dystonia. Therefore, the aim of this research has been to characterize thermal sensitivity in baseline conditions and hyperalgesia to heat after the induction of neuropathic pain through the spinal nerve ligation (SNL) model in mice overexpressing human wild-type and mutated torsin A in comparison to non-transgenic C57BL/6 mice. According to our results, the paw withdrawal latency time to heat in the Hargreaves’ test is significantly lower in the hMT mice (Kruskal–Wallis test = 6.933; p = 0.0312*; hMT vs. hWT p = 0.0317*). On the other hand, no significant differences in SNL-induced thermal hyperalgesia was found among the three strains (Friedman test = 4.933; p = 0.1019). Future studies are needed to better understand the role of torsin A in sensory processing of heat stimuli.
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Affiliation(s)
- Damiana Scuteri
- Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy;
- Regional Center for Serious Brain Injuries, S. Anna Institute, 88900 Crotone, Italy;
- Correspondence: (D.S.); (G.B.); Tel.: +39-0984/493462 (D.S. & G.B.)
| | - Laura Rombolà
- Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy;
| | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Antonio Pisani
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.P.); (P.B.)
- IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Paola Bonsi
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.P.); (P.B.)
| | - Kengo Hamamura
- Laboratory of Chemical Pharmacology, Faculty of Pharmaceutical Sciences, Daiichi University of Pharmacy, Fukuoka 815-8511, Japan;
| | - Giacinto Bagetta
- Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy;
- Correspondence: (D.S.); (G.B.); Tel.: +39-0984/493462 (D.S. & G.B.)
| | - Paolo Tonin
- Regional Center for Serious Brain Injuries, S. Anna Institute, 88900 Crotone, Italy;
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Tödt I, Baumann A, Knutzen A, Granert O, Tzvi E, Lindert J, Wolff S, Witt K, Zeuner KE. Abnormal effective connectivity in the sensory network in writer's cramp. Neuroimage Clin 2021; 31:102761. [PMID: 34298476 PMCID: PMC8378794 DOI: 10.1016/j.nicl.2021.102761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Writer's cramp (WC), a task specific form of dystonia, is considered to be a motor network disorder, but abnormal sensory tactile processing has also been acknowledged. The sensory spatial discrimination threshold (SDT) can be determined with a spatial acuity test (JVP domes). In addition to increased SDT, patients with WC exhibited dysfunctional sensory processing in the sensory cortex, insula, basal ganglia and cerebellum in a functional magnetic resonance imaging (fMRI) study while performing the spatial acuity test. OBJECTIVES To assess whether effective connectivity (EC) in the sensory network including cortical, basal ganglia, thalamic and cerebellar regions of interest in WC patients is abnormal. METHODS We used fMRI and applied a block design, while 19 WC patients and 13 age-matched healthy controls performed a spatial discrimination task. Before we assessed EC using dynamic causal modelling, we compared three model structures based on the current literature. We enclosed regions of interest that are established for sensory processing during right hand stimulation: Left thalamus, somatosensory, parietal and insular cortex, posterior putamen, and right cerebellum. RESULTS The EC analysis revealed task-dependent decreased unidirectional connectivity between the insula and the posterior putamen. The connectivity involving the primary sensory cortex, parietal cortex and cerebellum were not abnormal in WC. The two groups showed no differences in their behavioural data. CONCLUSIONS Perception and integration of sensory information requires the exchange of information between the insula cortex and the putamen, a sensory process that was disturbed in WC patients.
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Affiliation(s)
- Inken Tödt
- Department of Neurology, Kiel University, Germany.
| | | | - Arne Knutzen
- Department of Neurology, Kiel University, Germany
| | | | - Elinor Tzvi
- Department of Neurology, Leipzig University, Germany
| | - Julia Lindert
- Brighton and Sussex University Hospitals NHS Trust, UK
| | | | - Karsten Witt
- Department of Neurology and Research Center Neurosensory Science, School of Medicine and Health Sciences - European Medical School, Carl von Ossietzky University, Oldenburg, Germany
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Listik C, Cury RG, da Silva VA, Casagrande SCB, Listik E, Link N, Galhardoni R, Barbosa ER, Teixeira MJ, Ciampi de Andrade D. Abnormal sensory thresholds of dystonic patients are not affected by deep brain stimulation. Eur J Pain 2021; 25:1355-1366. [PMID: 33740316 DOI: 10.1002/ejp.1757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Unlike motor symptoms, the effects of deep brain stimulation (DBS) on non-motor symptoms associated with dystonia remain unknown. METHODS The objective of this study was to assess the effects of DBS on evoked experimental pain and cutaneous sensory thresholds in a crossover, double-blind on/off study and compare these results with those of healthy volunteers (HV). RESULTS Sixteen patients with idiopathic dystonia (39.9 ± 13 years old, n = 14 generalized) with DBS of the globus pallidus internus underwent a battery of quantitative sensory testing and assessment using a pain top-down modulation system (conditioned pain modulation, CPM). Results for the more and less dystonic body regions were compared in on and off stimulation. The patients' results were compared to age- and sex-matched HV. Descending pain modulation CPM responses in dystonic patients (on-DBS, 11.8 ± 40.7; off-DBS, 1.8 ± 22.1) was abnormally low (defective) compared to HV (-15.6 ± 23.5, respectively p = .006 and p = .042). Cold pain threshold and cold hyperalgesia were 54.8% and 95.7% higher in dystonic patients compared to HV. On-DBS CPM correlated with higher Burke-Fahn-Marsden disability score (r = 0.598; p = .014). While sensory and pain thresholds were not affected by DBS on/off condition, pain modulation was abnormal in dystonic patients and tended to be aggravated by DBS. CONCLUSION The analgesic effects after DBS do not seem to depend on short-duration changes in cutaneous sensory thresholds in dystonic patients and may be related to changes in the central processing of nociceptive inputs.
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Affiliation(s)
- Clarice Listik
- Movement Disorders Center, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Rubens Gisbert Cury
- Movement Disorders Center, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Valquiria Aparecida da Silva
- Pain Center, Neurosurgery Division, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | | | - Eduardo Listik
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Naira Link
- Pain Center, Neurosurgery Division, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Ricardo Galhardoni
- Pain Center, Neurosurgery Division, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil.,Federal University of ABC, São Bernardo do Campo, SP, Brazil.,School of Medicine, Santo André, SP, Brazil
| | - Egberto Reis Barbosa
- Movement Disorders Center, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Manoel Jacobsen Teixeira
- Pain Center, Neurosurgery Division, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Daniel Ciampi de Andrade
- Movement Disorders Center, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil.,Pain Center, Neurosurgery Division, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, SP, Brazil.,Pain Center, Instituto do Cancer do Estado de São Paulo, São Paulo, SP, Brazil
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Pérez-de-Heredia-Torres M, García-Bravo C, Huertas-Hoyas E, Martínez-Piédrola MR, Serrada-Tejeda S, Martínez-Castrillo JC. Sensitivity and pain in focal dystonia of the hand. Neurologia 2020; 37:S0213-4853(20)30043-8. [PMID: 32327198 DOI: 10.1016/j.nrl.2019.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/10/2019] [Accepted: 12/12/2019] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION A growing body of evidence highlights the importance of understanding both the sensory and the motor pathophysiology of focal dystonia in order to improve its treatment. This study aims to evaluate somatosensory afferences in patients with focal or segmental dystonia affecting the upper limbs, to analyse whether the dominant limb is more frequently affected, to analyse pain tolerance, and to examine the potential association with pain perception in patients with hand dystonia. METHODS We recruited 24 participants: 12 patients with focal hand dystonia and 12 individuals without dystonia. All participants were evaluated with a digital algometer (Somedic SenseLab AB®, Farsta, Sweden), a Semmes-Weinstein monofilament test, and the visual analogue scale for pain. RESULTS According to our data, patients showed greater impairment in surface sensitivity than controls, both in the dominant and the non-dominant hands, as well as greater presence of pain (P>.001). Furthermore, the dystonia group showed a negative correlation between perceived pain and pressure pain tolerance threshold (rho=-0.83; P<.001). CONCLUSIONS Patients with focal hand dystonia presented alterations in sensitivity and more severe perceived pain than individuals without dystonia. Future studies with larger samples should aim to analyse the clinical implications and everyday impact of both objective and subjective pain.
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Affiliation(s)
- M Pérez-de-Heredia-Torres
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
| | - C García-Bravo
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
| | - E Huertas-Hoyas
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, España.
| | - M R Martínez-Piédrola
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
| | - S Serrada-Tejeda
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
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Conte A, Defazio G, Mascia M, Belvisi D, Pantano P, Berardelli A. Advances in the pathophysiology of adult-onset focal dystonias: recent neurophysiological and neuroimaging evidence. F1000Res 2020; 9. [PMID: 32047617 PMCID: PMC6993830 DOI: 10.12688/f1000research.21029.2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 12/28/2022] Open
Abstract
Focal dystonia is a movement disorder characterized by involuntary muscle contractions that determine abnormal postures. The traditional hypothesis that the pathophysiology of focal dystonia entails a single structural dysfunction (i.e. basal ganglia) has recently come under scrutiny. The proposed network disorder model implies that focal dystonias arise from aberrant communication between various brain areas. Based on findings from animal studies, the role of the cerebellum has attracted increased interest in the last few years. Moreover, it has been increasingly reported that focal dystonias also include nonmotor disturbances, including sensory processing abnormalities, which have begun to attract attention. Current evidence from neurophysiological and neuroimaging investigations suggests that cerebellar involvement in the network and mechanisms underlying sensory abnormalities may have a role in determining the clinical heterogeneity of focal dystonias.
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Affiliation(s)
- Antonella Conte
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli (IS), Italy
| | - Giovanni Defazio
- Department of Medical Sciences and Public Health, Neurology Unit, University of Cagliari and AOU Cagliari, Monserrato, Cagliari, Italy
| | - Marcello Mascia
- Department of Medical Sciences and Public Health, Neurology Unit, University of Cagliari and AOU Cagliari, Monserrato, Cagliari, Italy
| | | | - Patrizia Pantano
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli (IS), Italy
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli (IS), Italy
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Salouchina NI, Nodel MR, Tolmacheva VA. [Non-motor disorders in patients with muscular dystonia]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 118:98-105. [PMID: 30335080 DOI: 10.17116/jnevro201811809198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Non-motor disturbances represented by sensory, affective, obsessive-compulsive disorders, cognitive dysfunction, sleep disturbances are often found in patients with dystonia and have a negative impact on their quality of life. The prevalence of sensory and affective disorders and sleep disturbances is above 50% in patients with cervical dystonia and is 25% in patients with blepharospasm, writing spasm; cognitive dysfunction is found in more than 25% of patients with focal dystonia. The relationship of non-motor, in particular psychiatric disorders, with the impairment of social and everyday life and worsening of quality of life in whole was shown. Common pathophysiological mechanisms of non-motor disorders as well as approaches to treatment of these disorders are discussed. The authors present the results on the positive effect of botulinum toxin therapy that reduces cognitive dysfunction, sensory disorders and depressive syndrome. Non-medication treatment of non-motor disorders in patients with dystonia is considered.
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Affiliation(s)
| | - M R Nodel
- Sechenov First Moscow State Medical University, Moscow, Russia; Pirogov Russian National Research Medical University ,Research and Clinical Center of Gerontology, Moscow, Russia
| | - V A Tolmacheva
- Sechenov First Moscow State Medical University, Moscow, Russia
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Paracka L, Wegner F, Blahak C, Abdallat M, Saryyeva A, Dressler D, Karst M, Krauss JK. Sensory Alterations in Patients with Isolated Idiopathic Dystonia: An Exploratory Quantitative Sensory Testing Analysis. Front Neurol 2017; 8:553. [PMID: 29089923 PMCID: PMC5650962 DOI: 10.3389/fneur.2017.00553] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/28/2017] [Indexed: 02/04/2023] Open
Abstract
Abnormalities in the somatosensory system are increasingly being recognized in patients with dystonia. The aim of this study was to investigate whether sensory abnormalities are confined to the dystonic body segments or whether there is a wider involvement in patients with idiopathic dystonia. For this purpose, we recruited 20 patients, 8 had generalized, 5 had segmental dystonia with upper extremity involvement, and 7 had cervical dystonia. In total, there were 13 patients with upper extremity involvement. We used Quantitative Sensory Testing (QST) at the back of the hand in all patients and at the shoulder in patients with cervical dystonia. The main finding on the hand QST was impaired cold detection threshold (CDT), dynamic mechanical allodynia (DMA), and thermal sensory limen (TSL). The alterations were present on both hands, but more pronounced on the side more affected with dystonia. Patients with cervical dystonia showed a reduced CDT and hot detection threshold (HDT), enhanced TSL and DMA at the back of the hand, whereas the shoulder QST only revealed increased cold pain threshold and DMA. In summary, QST clearly shows distinct sensory abnormalities in patients with idiopathic dystonia, which may also manifest in body regions without evident dystonia. Further studies with larger groups of dystonia patients are needed to prove the consistency of these findings.
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Affiliation(s)
- Lejla Paracka
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Florian Wegner
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Christian Blahak
- Faculty of Medicine Mannheim, Department of Neurology, University of Heidelberg, Mannheim, Germany
| | - Mahmoud Abdallat
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Assel Saryyeva
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Dirk Dressler
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Matthias Karst
- Department of Anesthesiology, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Center for Systems Neuroscience, Hannover, Germany.,Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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14
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Jahanshahi M. Neuropsychological and Neuropsychiatric Features of Idiopathic and DYT1 Dystonia and the Impact of Medical and Surgical treatment. Arch Clin Neuropsychol 2017; 32:888-905. [DOI: 10.1093/arclin/acx095] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Indexed: 11/14/2022] Open
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15
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de Tommaso M, Arendt-Nielsen L, Defrin R, Kunz M, Pickering G, Valeriani M. Pain in Neurodegenerative Disease: Current Knowledge and Future Perspectives. Behav Neurol 2016; 2016:7576292. [PMID: 27313396 PMCID: PMC4904074 DOI: 10.1155/2016/7576292] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/18/2016] [Accepted: 05/08/2016] [Indexed: 12/26/2022] Open
Abstract
Neurodegenerative diseases are going to increase as the life expectancy is getting longer. The management of neurodegenerative diseases such as Alzheimer's disease (AD) and other dementias, Parkinson's disease (PD) and PD related disorders, motor neuron diseases (MND), Huntington's disease (HD), spinocerebellar ataxia (SCA), and spinal muscular atrophy (SMA), is mainly addressed to motor and cognitive impairment, with special care to vital functions as breathing and feeding. Many of these patients complain of painful symptoms though their origin is variable, and their presence is frequently not considered in the treatment guidelines, leaving their management to the decision of the clinicians alone. However, studies focusing on pain frequency in such disorders suggest a high prevalence of pain in selected populations from 38 to 75% in AD, 40% to 86% in PD, and 19 to 85% in MND. The methods of pain assessment vary between studies so the type of pain has been rarely reported. However, a prevalent nonneuropathic origin of pain emerged for MND and PD. In AD, no data on pain features are available. No controlled therapeutic trials and guidelines are currently available. Given the relevance of pain in neurodegenerative disorders, the comprehensive understanding of mechanisms and predisposing factors, the application and validation of specific scales, and new specific therapeutic trials are needed.
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Affiliation(s)
- Marina de Tommaso
- Neurophysiopathology of Pain Section, SMBNOS Department, Bari Aldo Moro University, Bari, Italy
| | | | - Ruth Defrin
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Miriam Kunz
- Department of General Practice, Section Gerontology, University Medical Center Groningen, Groningen, Netherlands
| | - Gisele Pickering
- CHU Clermont-Ferrand, Centre de Pharmacologie Clinique, Clermont-Ferrand, France
- Inserm, CIC 1405, Neurodol 1107, 63003 Clermont-Ferrand, France
| | - Massimiliano Valeriani
- Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark
- Division of Neurology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
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16
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Non-motor symptoms in patients with adult-onset focal dystonia: Sensory and psychiatric disturbances. Parkinsonism Relat Disord 2016; 22 Suppl 1:S111-4. [DOI: 10.1016/j.parkreldis.2015.09.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 08/31/2015] [Accepted: 09/01/2015] [Indexed: 11/29/2022]
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17
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Rabey M, Beales D, Slater H, O'Sullivan P. Multidimensional pain profiles in four cases of chronic non-specific axial low back pain: An examination of the limitations of contemporary classification systems. ACTA ACUST UNITED AC 2015; 20:138-47. [DOI: 10.1016/j.math.2014.07.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/24/2014] [Accepted: 07/28/2014] [Indexed: 01/22/2023]
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18
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Beese LC, Putzer D, Osada N, Evers S, Marziniak M. Contact heat evoked potentials and habituation measured interictally in migraineurs. J Headache Pain 2015; 16:1. [PMID: 25564352 PMCID: PMC5395697 DOI: 10.1186/1129-2377-16-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 12/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A lack of habituation of different evoked potential modalities in migraine patients in-between attacks has been suggested. METHODS This study investigates cortical response after painful stimuli evaluated by contact heat evoked potentials (CHEPs) and quantitative sensory testing (QST) during the migraine-free interval. We enrolled 22 migraine patients and 22 healthy subjects. RESULTS Cortical potentials after contact heat stimulation of the cheeks and the volar forearm at a temperature of 51°C showed significantly reduced A-δ-amplitudes in patients and healthy controls. When the subjects' attention was drawn to an arithmetic task, a partial lack of habituation of amplitude could be seen in migraine patients. QST did not show any difference between migraineurs and controls. CONCLUSION Our findings can be primarily deemed to demonstrate that patients and healthy controls show significantly lower amplitudes while performing the calculation task. Without performing the calculation task we could not show the expected lack of habituation in migraineurs. Yet, while performing the calculation task our results partly suggest that hypothesis.
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Affiliation(s)
- Lena Clara Beese
- Department of General Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Denise Putzer
- Department of General Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Nani Osada
- Department of Medical Informatics and Biomathematics, University of Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Stefan Evers
- Krankenhaus Lindenbrunn, Lindenbrunn 1, 31863 Coppenbrügge, Germany
| | - Martin Marziniak
- Department of General Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- Department of Neurology, Isar-Amper-Clinic, Munic-East, Ringstrasse 56A, 85540 Haar, Germany
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Avanzino L, Fiorio M. Proprioceptive dysfunction in focal dystonia: from experimental evidence to rehabilitation strategies. Front Hum Neurosci 2014; 8:1000. [PMID: 25538612 PMCID: PMC4260499 DOI: 10.3389/fnhum.2014.01000] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/25/2014] [Indexed: 11/13/2022] Open
Abstract
Dystonia has historically been considered a disorder of the basal ganglia, mainly affecting planning and execution of voluntary movements. This notion comes from the observation that most lesions responsible for secondary dystonia involve the basal ganglia. However, what emerges from recent research is that dystonia is linked to the dysfunction of a complex neural network that comprises basal ganglia–thalamic–frontal cortex, but also the inferior parietal cortex and the cerebellum. While dystonia is clearly a motor problem, it turned out that sensory aspects are also fundamental, especially those related to proprioception. We outline experimental evidence for proprioceptive dysfunction in focal dystonia from intrinsic sensory abnormalities to impaired sensorimotor integration, which is the process by which sensory information is used to plan and execute volitional movements. Particularly, we will focus on proprioceptive aspects of dystonia, including: (i) processing of vibratory input, (ii) temporal discrimination of two passive movements, (iii) multimodal integration of visual-tactile and proprioceptive inputs, and (iv) motor control in the absence of visual feedback. We suggest that these investigations contribute not only to a better understanding of dystonia pathophysiology, but also to develop rehabilitation strategies aimed at facilitating the processing of proprioceptive input.
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Affiliation(s)
- Laura Avanzino
- Section of Human Physiology, Department of Experimental Medicine, Centro Polifunzionale di Scienze Motorie, University of Genoa , Genoa , Italy
| | - Mirta Fiorio
- Department of Neurological and Movement Sciences, University of Verona , Verona , Italy
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Cheng FPH, Großbach M, Altenmüller EO. Altered sensory feedbacks in pianist's dystonia: the altered auditory feedback paradigm and the glove effect. Front Hum Neurosci 2014; 7:868. [PMID: 24381552 PMCID: PMC3865372 DOI: 10.3389/fnhum.2013.00868] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 11/28/2013] [Indexed: 11/13/2022] Open
Abstract
Background: This study investigates the effect of altered auditory feedback (AAF) in musician's dystonia (MD) and discusses whether AAF can be considered as a sensory trick in MD. Furthermore, the effect of AAF is compared with altered tactile feedback, which can serve as a sensory trick in several other forms of focal dystonia. Methods: The method is based on scale analysis (Jabusch et al., 2004). Experiment 1 employs synchronization paradigm: 12 MD patients and 25 healthy pianists had to repeatedly play C-major scales in synchrony with a metronome on a MIDI-piano with three auditory feedback conditions: (1) normal feedback; (2) no feedback; (3) constant delayed feedback. Experiment 2 employs synchronization-continuation paradigm: 12 MD patients and 12 healthy pianists had to repeatedly play C-major scales in two phases: first in synchrony with a metronome, secondly continue the established tempo without the metronome. There are four experimental conditions, among them three are the same AAF as in Experiment 1 and 1 is related to altered tactile sensory input. The coefficient of variation of inter-onset intervals of the key depressions was calculated to evaluate fine motor control. Results: In both experiments, the healthy controls and the patients behaved very similarly. There is no difference in the regularity of playing between the two groups under any condition, and neither did AAF nor did altered tactile feedback have a beneficial effect on patients' fine motor control. Conclusions: The results of the two experiments suggest that in the context of our experimental designs, AAF and altered tactile feedback play a minor role in motor coordination in patients with musicians' dystonia. We propose that altered auditory and tactile feedback do not serve as effective sensory tricks and may not temporarily reduce the symptoms of patients suffering from MD in this experimental context.
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Affiliation(s)
- Felicia P-H Cheng
- Institute of Music Physiology and Musicians' Medicine, Hanover University of Music, Drama, and Media Hannover, Germany
| | - Michael Großbach
- Institute of Music Physiology and Musicians' Medicine, Hanover University of Music, Drama, and Media Hannover, Germany
| | - Eckart O Altenmüller
- Institute of Music Physiology and Musicians' Medicine, Hanover University of Music, Drama, and Media Hannover, Germany
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21
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Abstract
Movement disorders, which include disorders such as Parkinson's disease, dystonia, Tourette's syndrome, restless legs syndrome, and akathisia, have traditionally been considered to be disorders of impaired motor control resulting predominantly from dysfunction of the basal ganglia. This notion has been revised largely because of increasing recognition of associated behavioural, psychiatric, autonomic, and other non-motor symptoms. The sensory aspects of movement disorders include intrinsic sensory abnormalities and the effects of external sensory input on the underlying motor abnormality. The basal ganglia, cerebellum, thalamus, and their connections, coupled with altered sensory input, seem to play a key part in abnormal sensorimotor integration. However, more investigation into the phenomenology and physiological basis of sensory abnormalities, and about the role of the basal ganglia, cerebellum, and related structures in somatosensory processing, and its effect on motor control, is needed.
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Affiliation(s)
- Neepa Patel
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA.
| | - Mark Hallett
- Human Motor Control Section, NINDS, National Institutes of Health, Bethesda, MD, USA
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22
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Reproducibility of contact heat evoked potentials (CHEPs) over a 6months interval. Clin Neurophysiol 2013; 124:2242-7. [DOI: 10.1016/j.clinph.2013.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 02/01/2013] [Accepted: 05/08/2013] [Indexed: 01/02/2023]
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23
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van Rooijen DE, Marinus J, Schouten AC, Noldus LP, van Hilten JJ. Muscle Hyperalgesia Correlates With Motor Function in Complex Regional Pain Syndrome Type 1. THE JOURNAL OF PAIN 2013; 14:446-54. [DOI: 10.1016/j.jpain.2012.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 11/20/2012] [Accepted: 12/10/2012] [Indexed: 01/21/2023]
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24
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Baumgärtner U, Greffrath W, Treede RD. Contact heat and cold, mechanical, electrical and chemical stimuli to elicit small fiber-evoked potentials: Merits and limitations for basic science and clinical use. Neurophysiol Clin 2012; 42:267-80. [DOI: 10.1016/j.neucli.2012.06.002] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 06/05/2012] [Accepted: 06/25/2012] [Indexed: 12/13/2022] Open
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25
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Increased baseline temperature improves the acquisition of contact heat evoked potentials after spinal cord injury. Clin Neurophysiol 2012; 123:582-9. [DOI: 10.1016/j.clinph.2011.08.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 08/11/2011] [Accepted: 08/14/2011] [Indexed: 12/13/2022]
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26
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Tinazzi M, Valeriani M, Squintani G, Corrà F, Recchia S, Defazio G, Berardelli A. Nociceptive pathway function is normal in cervical dystonia: a study using laser-evoked potentials. J Neurol 2012; 259:2060-6. [DOI: 10.1007/s00415-012-6454-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 10/28/2022]
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Stamelou M, Edwards MJ, Hallett M, Bhatia KP. The non-motor syndrome of primary dystonia: clinical and pathophysiological implications. Brain 2011; 135:1668-81. [PMID: 21933808 DOI: 10.1093/brain/awr224] [Citation(s) in RCA: 207] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Dystonia is typically considered a movement disorder characterized by motor manifestations, primarily involuntary muscle contractions causing twisting movements and abnormal postures. However, growing evidence indicates an important non-motor component to primary dystonia, including abnormalities in sensory and perceptual functions, as well as neuropsychiatric, cognitive and sleep domains. Here, we review this evidence and discuss its clinical and pathophysiological implications.
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Affiliation(s)
- Maria Stamelou
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology Queen Square, London, WC1N 3BG UK
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