Is essential tremor a family of diseases or a syndrome? A family of diseases

It is now well-established that essential tremor (ET) can manifest with different clinical presentations and progressions (i.e., upper limb tremor, head tremor, voice tremor, lower limb tremor, task- or position-specific tremor, or a combination of those). Common traits and overlaps are identifiable across these different subtypes of ET, including a slow rate of progression, a response to alcohol and a positive family history. At the same time, each of these manifestations are associated with specific demographic, clinical and treatment-response characteristics suggesting a family of diseases rather than a spectrum of a syndrome. Here we summarize the most important clinical, demographic, neuropathological and imagingfeatures of ET and of its subtypes to support ET as a family of identifiable conditions. This classification has relevance for counseling of patients with regard to disease progression and treatment response, as well as for the design of therapeutic clinical trials.

An examination of a potential organized motor unit firing rate and recruitment scheme of an antagonist muscle during isometric contractions

The primary purpose of the present study is to determine if an organized control scheme exists for the antagonist muscle during steady isometric torque. A secondary focus is to better understand how firing rates of the antagonist muscle change from a moderate- to higher-contraction intensity. Fourteen subjects performed two submaximal isometric trapezoid muscle actions of the forearm flexors that included a linearly increasing, steady force at both 40% and 70% maximum voluntary contraction, and linearly decreasing segments. Surface electromyographic signals of the biceps and triceps brachii were collected and decomposed into constituent motor unit action potential trains. Motor unit firing rate versus recruitment threshold, motor unit action potential amplitude versus recruitment threshold, and motor unit firing rate versus action potential amplitude relationships of the biceps brachii (agonist) and triceps brachii (antagonist) muscles were analyzed. Moderate- to-strong relationships (|r| ≥ 0.69) were present for the agonist and antagonist muscles for each relationship with no differences between muscles (P = 0.716, 0.428, 0.182). The y-intercepts of the motor unit firing rate versus recruitment threshold relationship of the antagonist did not increase from 40% to 70% maximal voluntary contractions (P = 0.96), unlike for the agonist (P = 0.009). The antagonist muscle exhibits a similar motor unit control scheme to the agonist. Unlike the agonist, however, the firing rates of the antagonist did not increase with increasing intensity. Future research should investigate how antagonist firing rates adapt to resistance training and changes in antagonist firing rates in the absence of peripheral feedback.NEW & NOTEWORTHY This is the first study to explore a potential motor unit control scheme and quantify changes in firing rates with increasing intensity of an antagonist muscle during isometric contractions. We demonstrate that the antagonist muscle possesses an organized motor unit firing rate and recruitment scheme similar to the agonist muscle during isometric forearm flexion, but unlike the agonist muscle, there was no significant increase in firing rates from a moderate- to higher-intensity isometric contraction.

Aberrant Somatosensory-Motor Adaptation in Musicians' Dystonia

BACKGROUND

Some forms of movement disorders are characterized by task-specific manifestations of symptoms. However, its underlying mechanisms are poorly understood. Here we addressed this issue through a novel motor adaptation experimental paradigm.

METHODS

Pianists with and without focal task-specific dystonia learned to play the piano with a key whose weight can be modified by a novel robot system.

RESULTS

The result clearly demonstrated a significantly larger error between the target and produced keystroke velocities in the patients than the controls following a repetition of keystrokes of the weighted key. This adaptation failure was not correlated with the variability of timing and velocity of the keystroke when the patients were playing unloaded piano keys, which suggests distinct effects of focal task-specific dystonia on motor adaptation and fine motor control. Immediately after a repetition of the strikes of the heavy key with keeping the fingers adducted, the error of the keystroke velocity when striking the key with the fingers more abducted was maintained in both the patients and controls. This generalization of the adaptation across different hand postures suggests that motor memory of dynamics of the piano key is independent of biomechanical properties of the hand. Importantly, a lack of difference in the finger muscular strength between the groups indicated that the adaptation failure was not attributed to deficit of muscular strength in the patients.

CONCLUSIONS

These findings suggest that task-specific manifestation of dystonic movements in focal task-specific dystonia is associated with malfunctions of internal representation of mechanical properties of a well-trained tool. © 2020 International Parkinson and Movement Disorder Society.

State anxiety disorganizes finger movements during musical performance

Skilled performance, in many situations, exposes an individual to psychological stress and fear, thus triggering state anxiety and compromising motor dexterity. Suboptimal skill execution in people under pressure affects the future career prospects of trained individuals, such as athletes, clinicians, and musicians. However, it has not been elucidated in what manner state anxiety affects multijoint movements and thereby degrades fine motor control. Using principal component analysis of hand kinematics recorded by a data glove during piano performances, we tested whether state anxiety affects the organization of movements of multiple joints or merely constrains the amplitude of the individual joints without affecting joint movement coordination. The result demonstrated changes in the coordination of movements across joints in piano performances by experts under psychological stress. Overall, the change was characterized by reduction of synergistic movements between the finger responsible for the keypress and its adjacent fingers. A regression analysis further identified that the attenuation of the movement covariation between the fingers was associated with an increase in temporal error during performance under pressure. In contrast, neither the maximum nor minimum angles of the individual joints of the hand were susceptible to induced anxiety. These results suggest that degradation of fine motor control under pressure is mediated by incoordination of movements between the fingers in skilled piano performances. NEW & NOTEWORTHY A key issue in neuromuscular control of coordinated movements is how the nervous system organizes multiple degrees of freedom for production of skillful motor behaviors. We found that state anxiety disorchestrates the organization of finger movements so as to decrease synergistic motions between the fingers in musical performance, which degrades fine motor control. The findings are important to shed light on mechanisms underlying loss of motor dexterity under pressure.

Temporal exploration in sequential movements shapes efficient neuromuscular control

The interaction of early and deliberate practice with genetic predisposition endows experts with virtuosic motor performance. However, it has not been known whether ways of practicing shape motor virtuosity. Here, we addressed this issue by comparing the effects of rhythmic variation in motor practice on neuromuscular control of the finger movements in pianists. With the use of a novel electromyography system with miniature active electrodes, we recorded the activity of the intrinsic hand muscles of 27 pianists while they played the piano and analyzed it by using a nonnegative matrix factorization algorithm and cluster analysis. The result demonstrated that practicing a target movement sequence with various rhythms reduced muscular activity, whereas neither practicing a sequence with a single rhythm nor taking a rest without practicing changed the activity. In addition, practice with rhythmic variation changed the patterns of simultaneous activations across muscles. This alteration of muscular coordination was associated with decreased activation of muscles not only relevant to, but also irrelevant to the task performance. In contrast, piano practice improved the maximum speed of the performance, the amount of which was independent of whether rhythmic variation was present. These results suggest that temporal variation in movement sequences during practice co-optimizes both movement speed and neuromuscular efficiency, which emphasizes the significance of ways of practice in the acquisition of motor virtuosity. NEW & NOTEWORTHY A key question in motor neuroscience is whether "ways of practicing" contribute to shaping motor virtuosity. We found both attenuation of activities and alteration of coordination of the intrinsic hand muscles of pianists, specifically through practicing a movement sequence with various rhythms. The maximum speed of the finger movements was also enhanced following the practice. These results emphasize the importance of ways of practicing in facilitating multiple skills: efficiency and speed.

Kinematic Origins of Motor Inconsistency in Expert Pianists

For top performers, including athletes and musicians, even subtle inconsistencies in rhythm and force during movement production decrease the quality of performance. However, extensive training over many years beginning in childhood is unable to perfect dexterous motor performance so that it is without any error. To gain insight into the biological mechanisms underlying the subtle defects of motor actions, the present study sought to identify the kinematic origins of inconsistency of dexterous finger movements in musical performance. Seven highly-skilled pianists who have won prizes at international piano competitions played a short sequence of tones with the right hand at a predetermined tempo. Time-varying joint angles of the fingers were recorded using a custom-made data glove, and the timing and velocity of the individual keystrokes were recorded from a digital piano. Both ridge and stepwise multiple regression analyses demonstrated an association of the inter-trial variability of the inter-keystroke interval (i.e., rhythmic inconsistency) with both the rotational velocity of joints of the finger used for a keystroke (i.e., striking finger) and the movement independence between the striking and non-striking fingers. This indicates a relationship between rhythmic inconsistency in musical performance and the dynamic features of movements in not only the striking finger but also the non-striking fingers. In contrast, the inter-trial variability of the key-descending velocity (i.e., loudness inconsistency) was associated mostly with the kinematic features of the striking finger at the moment of the keystroke. Furthermore, there was no correlation between the rhythmic and loudness inconsistencies. The results suggest distinct kinematic origins of inconsistencies in rhythm and loudness in expert musical performance.

Maladaptive Plasticity Induces Degradation of Fine Motor Skills in Musicians

Abstract. Performing music at a professional level is probably one of the most complex human accomplishments requiring extensive training periods. The superior skills of musicians are mirrored in plastic adaptations of the brain involving gray and white matter increase in sensory motor and auditory areas and enlargement of receptive fields. Motor disturbances in musicians are common and include mild forms, such as temporary motor fatigue, painful overuse injuries following prolonged practice, anxiety-related motor failures during performances, and more persistent losses of motor control, termed “dynamic stereotypes.” Musician’s dystonia is characterized by a permanent loss of motor control when playing a musical instrument linked to genetic susceptibility and to maladaptive plasticity. In this review article, we argue that these motor failures developing on a continuum from motor fatigue to musician’s dystonia require client tailored treatment and accordingly specific psychological and neurological interventions.

Task-specific kinetic finger tremor affects the performance of carrom players

We aimed to determine the effect of task-specific kinetic finger tremor, as indexed by surface electromyography (EMG), on the accuracy of a carrom stroke. Surface EMG of extensor digitorum communis muscle of the playing arm was recorded during rest, isometric contraction and stroke execution in 17 male carrom players with clinically observed finger tremor and 18 skill- and age-matched controls. Log-transformed power spectral densities (LogPSDs) of surface EMG activity (signifying tremor severity) at a 1-s pre-execution period correlated with angular error of the stroke. LogPSDs in 4-10 Hz range were higher in players with tremor than controls during pre-execution (P < 0.001), but not during the resting state (P = 0.067). Pre-execution tremor amplitude correlated with angular deviation (r = 0.45, P = 0.007). For the first time, we document a task-specific kinetic finger tremor in carrom players. This finger tremor during the immediate pre-execution phase appears to be a significant determinant of stroke accuracy.

Acquisition and reacquisition of motor coordination in musicians

Precise control of movement timing plays a key role in musical performance. This motor skill requires coordination across multiple joints and muscles, which is acquired through extensive musical training from childhood. However, extensive training has a potential risk of causing neurological disorders that impair fine motor control, such as task-specific tremor and focal dystonia. Recent technological advances in measurement and analysis of biological data, as well as noninvasive manipulation of neuronal activities, have promoted the understanding of computational and neurophysiological mechanisms underlying acquisition, loss, and reacquisition of dexterous movements through musical practice and rehabilitation. This paper aims to provide an overview of the behavioral and neurophysiological basis of motor virtuosity and disorder in musicians, representative extremes of human motor skill. We also report novel evidence of effects of noninvasive neurorehabilitation that combined transcranial direct-current stimulation and motor rehabilitation over multiple days on musician's dystonia, which offers a promising therapeutic means.

Apollo's curse: neurological causes of motor impairments in musicians

Performing music at a professional level is probably one of the most complex human accomplishments. Extremely fast and complex, temporo-spatially predefined movement patterns have to be learned, memorized, and retrieved with high reliability in order to meet the expectations of listeners. Performing music requires not only the integration of multimodal sensory and motor information, and its precise monitoring via auditory and kinesthetic feedback, but also emotional communicative skills, which provide a "speaking" rendition of a musical masterpiece. To acquire these specialized auditory-sensory-motor and emotional skills, musicians must undergo extensive training periods over many years, which start in early childhood and continue on through stages of increasing physical and strategic complexities. Performance anxiety, linked to high societal pressures such as the fear of failure and heightened self-demands, frequently accompanies these learning processes. Motor disturbances in musicians are common and include mild forms, such as temporary motor fatigue with short-term reduction of motor skills, painful overuse injuries following prolonged practice, anxiety-related motor failures during performances (choking under pressure), as well as more persistent losses of motor control, here termed "dynamic stereotypes" (DSs). Musician's dystonia (MD), which is characterized by the permanent loss of control of highly skilled movements when playing a musical instrument, is the gravest manifestation of dysfunctional motor programs, frequently linked to a genetic susceptibility to develop such motor disturbances. In this review chapter, we focus on different types of motor failures in musicians. We argue that motor failures in musicians develop along a continuum, starting with subtle transient degradations due to fatigue, overuse, or performance stress, which transform by and by into more permanent, still fluctuating motor degradations, the DSs, until a more irreversible condition, MD manifests. We will review the epidemiology and the principles of medical treatment of MD and discuss prevention strategies.

Quantification of a secondary task-specific tremor in a violinist after a temporal lobectomy

Task-specific tremors (TSTs) occur mainly during certain tasks and may be highly disabling. In this case study, we report on a 66-year-old violinist who developed a TST of the right arm only while playing the violin 4 weeks after a temporal lobectomy, which had been performed as a result of his temporal lobe epilepsy. Since a similar case, to our knowledge, has not been reported so far, our aim was to quantitatively assess and describe the tremor by measuring (a) the electromyography (EMG) activity of the wrist flexor and extensor as well as (b) an accelerometer signal of the hand. We found a tremor-related frequency of about 7 Hz. Furthermore, at a similar frequency of about 7 Hz, there was coherence between the tremor acceleration and EMG-activity of the wrist flexor and extensor as well as between the tremor acceleration and coactivation. The tremorgenesis remains unclear, and possible explanations can only be speculative.

Movement induced tremor in musicians and non-musicians reflects adaptive brain plasticity

Evidence exists that motor dexterity is associated with a higher tremor amplitude of physiological tremor. Likewise, lower frequencies are associated with motor control. So far only case reports of a higher amplitude of physiological tremor in musicians exist. Moreover, no study has investigated lower frequencies during a finger movement task in musicians who can be regarded as a model of motor expertise. We developed a model and derived three hypotheses which we investigated in this study: (1) Tremor amplitude is higher in the range of physiological tremor and (2) higher for frequency ranges of dystonic tremor in musicians compared to non-musicians; (3) there is no difference in tremor amplitude at frequencies below 4 Hz. We measured tremor during a finger flexion-extension movement in 19 musicians (age 26.5 ± 8.2 years) and 24 age matched non-musicians (age 26.5 ± 8.7). By using empirical mode decomposition in combination with a Hilbert transform we obtained the instantaneous frequency and amplitude, allowing to compare tremor amplitudes throughout the movement at various frequency ranges. We found a significantly higher tremor amplitude in musicians for physiological tremor and a tendency toward a higher amplitude during most of the movement in the frequency range of 4-8 Hz, which, however, was not significant. No difference was found in the frequency range below 4 Hz for the flexion and for almost the entire extension movement. Our results corroborate findings that the 8-12 Hz oscillatory activity plays a role in motor dexterity. However, our results do not allow for the conclusion that tremor at the frequency range of 4-8 Hz is related to either plasticity induced changes that are beneficial for motor skill development nor to maladaptive changes as, e.g., focal dystonia.

Electrophysiological characteristics of task-specific tremor in 22 instrumentalists

Our aim was to address three characteristics of task-specific tremor in musicians (TSTM): First, we quantified muscular activity of flexor and extensor muscles, of coactivation as well as tremor acceleration. Second, we compared muscular activity between task-dependent and position-dependent tremor. Third, we investigated, whether there is an overflow of muscular activity to muscles adjacent to the affected muscles in TSTM. Tremor acceleration and muscular activity were measured in the affected muscles and the muscles adjacent to the affected muscles in 22 patients aged 51.5 ± 11.4 years with a task-specific tremor. We assessed power of muscular oscillatory activity and calculated the coherence between EMG activity of affected muscles and tremor acceleration as well as between adjacent muscles and tremor acceleration. This was done for task-dependent and position-dependent tremor. We found the highest power and coherence of muscular oscillatory activity in the frequency range of 3-8 Hz for affected and adjacent muscles. No difference was found between task-dependent and position-dependent tremor in neither power nor coherence measures. Our results generalize previous results of a relation between coactivation and tremor among a variety of musicians. Furthermore, we found coherence of adjacent muscles and TSTM. This indicates that overflow exists in TSTM and suggests an association of TST with dystonia.

Analysis of dystonic tremor in musicians using empirical mode decomposition

OBJECTIVE

Test the hypotheses that tremor amplitude in musicians with task-specific dystonia is higher at the affected finger (dystonic tremor, DT) or the adjacent finger (tremor associated with dystonia, TAD) than (1) in matched fingers of healthy musicians and non-musicians and (2) within patients in the unaffected and non-adjacent fingers of the affected side within patients.

METHODS

We measured 21 patients, 21 healthy musicians and 24 non-musicians. Participants exerted a flexion-extension movement. Instantaneous frequency and amplitude values were obtained with empirical mode decomposition and a Hilbert-transform, allowing to compare tremor amplitudes throughout the movement at various frequency ranges.

RESULTS

We did not find a significant difference in tremor amplitude between patients and controls for either DT or TAD. Neither differed tremor amplitude in the within-patient comparisons.

CONCLUSION

Both hypotheses were rejected and apparently neither DT nor TAD occur in musician's dystonia of the fingers.

SIGNIFICANCE

This is the first study assessing DT and TAD in musician's dystonia. Our finding suggests that even though MD is an excellent model for malplasticity due to excessive practice, it does not seem to provide a good model for DT. Rather it seems that musician's dystonia may manifest itself either as dystonic cramping without tremor or as task-specific tremor without overt dystonic cramping.

Coherence of coactivation and acceleration in task-specific primary bowing tremor

Coherences between coactivation of wrist antagonist muscles and movement fluctuation were assessed in four violinists with a task-specific tremor and four age-matched healthy violinists using electromyography and accelerometer. We found coherence between individual muscular activation and tremor only in patients at a frequency range of 3-8 Hz. The finding corroborates the notion that primary bowing tremor emerges mainly due to central neurogenic contributions via motor-unit synchronization. Furthermore, the coherence between the muscular coactivation and tremor suggests a relation of the tremor to dystonia.