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Roytman S, Paalanen R, Carli G, Marusic U, Kanel P, van Laar T, Bohnen NI. Multisensory mechanisms of gait and balance in Parkinson's disease: an integrative review. Neural Regen Res 2025; 20:82-92. [PMID: 38767478 PMCID: PMC11246153 DOI: 10.4103/nrr.nrr-d-23-01484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/18/2024] [Indexed: 05/22/2024] Open
Abstract
Understanding the neural underpinning of human gait and balance is one of the most pertinent challenges for 21st-century translational neuroscience due to the profound impact that falls and mobility disturbances have on our aging population. Posture and gait control does not happen automatically, as previously believed, but rather requires continuous involvement of central nervous mechanisms. To effectively exert control over the body, the brain must integrate multiple streams of sensory information, including visual, vestibular, and somatosensory signals. The mechanisms which underpin the integration of these multisensory signals are the principal topic of the present work. Existing multisensory integration theories focus on how failure of cognitive processes thought to be involved in multisensory integration leads to falls in older adults. Insufficient emphasis, however, has been placed on specific contributions of individual sensory modalities to multisensory integration processes and cross-modal interactions that occur between the sensory modalities in relation to gait and balance. In the present work, we review the contributions of somatosensory, visual, and vestibular modalities, along with their multisensory intersections to gait and balance in older adults and patients with Parkinson's disease. We also review evidence of vestibular contributions to multisensory temporal binding windows, previously shown to be highly pertinent to fall risk in older adults. Lastly, we relate multisensory vestibular mechanisms to potential neural substrates, both at the level of neurobiology (concerning positron emission tomography imaging) and at the level of electrophysiology (concerning electroencephalography). We hope that this integrative review, drawing influence across multiple subdisciplines of neuroscience, paves the way for novel research directions and therapeutic neuromodulatory approaches, to improve the lives of older adults and patients with neurodegenerative diseases.
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Affiliation(s)
- Stiven Roytman
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Rebecca Paalanen
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Giulia Carli
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI, USA
| | - Uros Marusic
- Institute for Kinesiology Research, Science and Research Centre Koper, Koper, Slovenia
- Department of Health Sciences, Alma Mater Europaea - ECM, Maribor, Slovenia
| | - Prabesh Kanel
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI, USA
- Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI, USA
| | - Teus van Laar
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nico I Bohnen
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI, USA
- Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Bohnen NI, Marusic U, Roytman S, Paalanen R, Michalakis F, Brown T, Scott PJH, Carli G, Albin RL, Kanel P. Dynamic balance and gait impairments in Parkinson's disease: novel cholinergic patterns. Brain Commun 2024; 6:fcae286. [PMID: 39252998 PMCID: PMC11382145 DOI: 10.1093/braincomms/fcae286] [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: 02/06/2024] [Revised: 05/16/2024] [Accepted: 08/22/2024] [Indexed: 09/11/2024] Open
Abstract
The cholinergic system has been implicated in postural deficits, in particular falls, in Parkinson's disease (PD). Falls and freezing of gait typically occur during dynamic and challenging balance and gait conditions, such as when initiating gait, experiencing postural perturbations, or making turns. However, the precise cholinergic neural substrate underlying dynamic postural and gait changes remains poorly understood. The aim of this study was to investigate whether brain vesicular acetylcholine transporter binding, as measured with [18F]-fluoroethoxybenzovesamicol binding PET, correlates with dynamic gait and balance impairments in 125 patients with PD (mean age 66.89 ± 7.71 years) using the abbreviated balance evaluation systems test total and its four functional domain sub-scores (anticipatory postural control, reactive postural control, dynamic gait, and sensory integration). Whole brain false discovery-corrected (P < 0.05) correlations for total abbreviated balance evaluation systems test scores included the following bilateral or asymmetric hemispheric regions: gyrus rectus, orbitofrontal cortex, anterior part of the dorsomedial prefrontal cortex, dorsolateral prefrontal cortex, cingulum, frontotemporal opercula, insula, fimbria, right temporal pole, mesiotemporal, parietal and visual cortices, caudate nucleus, lateral and medial geniculate bodies, thalamus, lingual gyrus, cerebellar hemisphere lobule VI, left cerebellar crus I, superior cerebellar peduncles, flocculus, and nodulus. No significant correlations were found for the putamen or anteroventral putamen. The four domain-specific sub-scores demonstrated overlapping cholinergic topography in the metathalamus, fimbria, thalamus proper, and prefrontal cortices but also showed distinct topographic variations. For example, reactive postural control functions involved the right flocculus but not the upper brainstem regions. The anterior cingulum associated with reactive postural control whereas the posterior cingulum correlated with anticipatory control. The spatial extent of associated cholinergic system changes were least for dynamic gait and sensory orientation functional domains compared to the anticipatory and reactive postural control functions. We conclude that specific aspects of dynamic balance and gait deficits in PD associate with overlapping but also distinct patterns of cerebral cholinergic system changes in numerous brain regions. Our study also presents novel evidence of cholinergic topography involved in dynamic balance and gait in PD that have not been typically associated with mobility disturbances, such as the right anterior temporal pole, right anterior part of the dorsomedial prefrontal cortex, gyrus rectus, fimbria, lingual gyrus, flocculus, nodulus, and right cerebellar hemisphere lobules VI and left crus I.
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Affiliation(s)
- Nicolaas I Bohnen
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105-9755, USA
| | - Uros Marusic
- Institute for Kinesiology Research, Science and Research Centre Koper, 6000 Koper, Slovenia, EU
- Department of Health Sciences, Alma Mater Europaea University, 2000 Maribor, Slovenia, EU
| | - Stiven Roytman
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105-9755, USA
| | - Rebecca Paalanen
- Department of Neurology, University of Michigan, Ann Arbor, MI 48105-9755, USA
| | - Fotini Michalakis
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105-9755, USA
| | - Taylor Brown
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105-9755, USA
| | - Peter J H Scott
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105-9755, USA
| | - Giulia Carli
- Department of Neurology, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105-9755, USA
| | - Roger L Albin
- Department of Neurology, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105-9755, USA
| | - Prabesh Kanel
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105-9755, USA
- Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48105-9755, USA
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Seuthe J, Hermanns H, Hulzinga F, D'Cruz N, Deuschl G, Ginis P, Nieuwboer A, Schlenstedt C. Gait asymmetry and symptom laterality in Parkinson's disease: two of a kind? J Neurol 2024; 271:4373-4382. [PMID: 38652262 PMCID: PMC11233399 DOI: 10.1007/s00415-024-12379-0] [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: 03/15/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The laterality of motor symptoms is considered a key feature of Parkinson's disease (PD). Here, we investigated whether gait and turning asymmetry coincided with symptom laterality as determined by the MDS-UPRDS part III and whether it was increased compared to healthy controls (HC). METHODS We analyzed the asymmetry of gait and turning with and without a cognitive dual task (DT) using motion capture systems and wearable sensors in 97 PD patients mostly from Hoehn & Yahr stage II and III and 36 age-matched HC. We also assessed motor symptom asymmetry using the bilateral sub-items of the MDS-UPDRS-III. Finally, we examined the strength of the association between gait asymmetry and symptom laterality. RESULTS Participants with PD had increased gait but not more turning asymmetry compared to HC (p < 0.05). Only 53.7% of patients had a shorter step length on the more affected body side as determined by the MDS-UPDRS-III. Also, 54% took more time and 29% more steps during turns toward the more affected side. The degree of asymmetry in the different domains did not correlate with each other and was not influenced by DT-load. CONCLUSIONS We found a striking mismatch between the side and the degree of asymmetry in different motor domains, i.e., in gait, turning, and distal symptom severity in individuals with PD. We speculate that motor execution in different body parts relies on different neural control mechanisms. Our findings warrant further investigation to understand the complexity of gait asymmetry in PD.
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Affiliation(s)
- Jana Seuthe
- Institute of Interdisciplinary Exercise Science and Sports Medicine, Medical School Hamburg, Hamburg, Germany.
- Department of Neurology, Christian-Albrechts-University Kiel, University Hospital Schleswig-Holstein, Kiel, Germany.
| | - Helen Hermanns
- Department of Neurology, Christian-Albrechts-University Kiel, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Femke Hulzinga
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Louvain, Belgium
| | - Nicholas D'Cruz
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Louvain, Belgium
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University Kiel, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Pieter Ginis
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Louvain, Belgium
| | - Alice Nieuwboer
- Neuromotor Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven, Louvain, Belgium
| | - Christian Schlenstedt
- Institute of Interdisciplinary Exercise Science and Sports Medicine, Medical School Hamburg, Hamburg, Germany
- Department of Neurology, Christian-Albrechts-University Kiel, University Hospital Schleswig-Holstein, Kiel, Germany
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Jiang Y, Zhou M, Sheng H, Xu S, Chen Y, Wu L, He Q, Zhao L, Liu J, Chen W. Vestibular-evoked myogenic potential abnormalities in Parkinson's disease with freezing of gait. J Neurol 2024; 271:3527-3536. [PMID: 38538775 DOI: 10.1007/s00415-024-12311-6] [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: 12/23/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Vestibular dysfunction is closely associated with the pathophysiology of Parkinson's disease (PD) accompanied by freezing of gait (FOG); however, evidence supporting this clinical association is lacking. Vestibular-evoked myogenic potentials (VEMPs) have been widely acknowledged as a crucial electrophysiological parameter in the clinical evaluation of vestibular function. OBJECTIVE The present study investigated the possible correlation of FOG occurrence with VEMP observations in patients diagnosed with PD. METHODS Altogether, 95 idiopathic PD patients were recruited into the present cross-sectional study. All patients underwent motor and non-motor assessments using serial scales. In addition, the electrophysiological vestibular evaluation was conducted, which included cervical (cVEMP) and ocular VEMP (oVEMP) assessments. Furthermore, the correlations of bilateral c/oVEMP absence with clinical phenotypes, especially FOG, among the PD patients were analyzed. RESULTS Among the 95 patients with PD, 44 (46.3%) had bilateral oVEMP absence and 23 (24.2%) had bilateral cVEMP absence, respectively. The proportions of patients with bilateral oVEMP absence (77.8% vs 30.9%, p = 0.004) and bilateral cVEMP absence (44.4% vs 19.5%, p = 0.035) were higher in the patient group exhibiting FOG than in the group without FOG. Following the adjustment of confounding variables, bilateral oVEMP absence (OR = 8.544, p = 0.007), rather than bilateral cVEMP absence, was shown to independently predict FOG occurrence in patients with PD. CONCLUSION The close correlation between bilateral oVEMP absence and FOG in PD patients sheds new light on the possible role of central vestibular/upper brainstem dysfunction in FOG development in patients with PD.
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Affiliation(s)
- Yuhan Jiang
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengxi Zhou
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haibin Sheng
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Ear Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Shuai Xu
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Ear Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Yajing Chen
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Wu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing He
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Zhao
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianren Liu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Chen
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Wang X, Mei S, Lin Z, Huang Z, Mao W, Chan P. Impaired vestibular function associated with orthostatic hypotension in patients with multiple system atrophy. J Neurol 2024; 271:3486-3495. [PMID: 38528162 DOI: 10.1007/s00415-024-12324-1] [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: 01/18/2024] [Revised: 03/08/2024] [Accepted: 03/09/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Orthostatic hypotension (OH) is one of the most common symptoms in patients with multiple system atrophy (MSA). Vestibular system plays an important role in blood pressure regulation during orthostatic challenges through vestibular-sympathetic reflex. The current study aimed to investigate the relationship between vestibular function and OH in patients with MSA. METHODS Participants with MSA, including 20 with OH (mean age, 57.55 ± 8.44 years; 7 females) and 15 without OH (mean age, 59.00 ± 8.12 years; 2 females) and 18 healthy controls (mean age, 59.03 ± 6.44 years; 8 females) were enrolled. Cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs) tests were conducted to evaluate vestibular function. RESULTS Patients with MSA presented with significantly higher rate of absent cVEMPs (57.1% vs 11.1%, p = 0.001) and oVEMPs (25.7% vs 0, p = 0.021) than controls. MSA patients with OH showed more absent cVEMPs (75.0% vs 11.1%, Bonferroni corrected p < 0.001) and oVEMPs (40.0% vs 0, Bonferroni corrected p = 0.003) than controls. Patients with OH also showed higher rate of absent cVEMPs than those without OH (33.3%, Bonferroni corrected p = 0.014). CONCLUSIONS Our results demonstrated that impairment of vestibular function was associated with MSA, particularly in those with OH. Absent VEMPs may be a potential marker for MSA severity. Our findings suggest that impaired vestibular function is involved in OH development and may serve as an intervention target.
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Affiliation(s)
- Xue Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shanshan Mei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Key Laboratory on Parkinson's Disease of Beijing, Beijing, China
| | - Zhongxi Lin
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhaoyang Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Neuromodulation, Beijing, China
| | - Wei Mao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
- Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Key Laboratory on Parkinson's Disease of Beijing, Beijing, China.
| | - Piu Chan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
- Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Key Laboratory on Parkinson's Disease of Beijing, Beijing, China.
- Parkinson's Disease Center of Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China.
- National Clinical Research Center for Geriatric Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Yoritaka A, Hayashi T, Fusegi K, Nakayama S, Haneda J, Hattori N. Hypoperfusion in Supramarginal and Orbital Gyrus, Position Discrimination Test, and Microsaccades as a Predictor of Pisa Syndrome in Parkinson's Disease. PARKINSON'S DISEASE 2024; 2024:5550362. [PMID: 38846136 PMCID: PMC11156507 DOI: 10.1155/2024/5550362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/27/2024] [Accepted: 05/13/2024] [Indexed: 06/09/2024]
Abstract
Patients with Parkinson's disease (PD) experience significantly reduced quality of life when PD is complicated with Pisa syndrome (PS). PS is a postural abnormality associated with a lateral bending of the trunk, causing the patient to lean to one side. Microsaccades during fixation are transmitted to the visual cortex, and this gaze movement may be impaired in PD. We aimed to detect presymptomatic signs of PS. We enrolled 50 patients with PD without dementia and investigated the visual systems in patients with concurrent PD and PS based on a Romberg ratio of<1.0. Gaze analysis, pupil diameter, stabilization tests, neuropsychological tests, and cerebral perfusion scintigraphy were reviewed and statistically analyzed. Two years later, we divided the patients into three groups as follows: PISA++ (patients who had PS at enrollment), PISA-+ (patients without PS that developed PS during the 2-year period), and PISA-- (patients without PS that did not develop PS during the 2-year period). The PISA-+ group exhibited a significantly higher daily levodopa dose and longer fixations, as well as lower position discrimination, Wechsler Adult Intelligence Scale-Third Edition blocking, and blood flow in the left supramarginal and orbital gyri than that in the PISA-- group. The PISA++ group showed a significantly longer fixation time and lower Mini-Mental State Examination score, Romberg ratio of area, amplitude, velocity of microsaccades, and blood flow in the left precuneus and cuneus than that in the PISA-+ group. Before the onset of PS, hypoperfusion occurred in the correlative visual cortex and the position discrimination test. Patients with PS have reduced saccades and slow microsaccades.
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Affiliation(s)
- Asako Yoritaka
- Department of Neurology, Juntendo University Koshigaya Hospital, Saitama 343-0032, Japan
| | - Tetsuo Hayashi
- Department of Neurology, Juntendo University Koshigaya Hospital, Saitama 343-0032, Japan
| | - Keiko Fusegi
- Department of Neurology, Juntendo University Koshigaya Hospital, Saitama 343-0032, Japan
| | - Sachiko Nakayama
- Department of Neurology, Juntendo University Koshigaya Hospital, Saitama 343-0032, Japan
| | - Jun Haneda
- Department of Radiology, Koshigaya Municipal Hospital, Saitama 343-8577, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
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Gui M, Lv L, Qin L, Wang C. Vestibular dysfunction in Parkinson's disease: a neglected topic. Front Neurol 2024; 15:1398764. [PMID: 38846039 PMCID: PMC11153727 DOI: 10.3389/fneur.2024.1398764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/14/2024] [Indexed: 06/09/2024] Open
Abstract
Dizziness and postural instability are frequently observed symptoms in patient with Parkinson's disease (PD), potentially linked to vestibular dysfunction. Despite their significant impact on quality of life, these symptoms are often overlooked and undertreated in clinical practice. This review aims to summarize symptoms associated with vestibular dysfunction in patients with PD and discusses vestibular-targeted therapies for managing non-specific dizziness and related symptoms. We conducted searches in PubMed and Web of Science using keywords related to vestibular dysfunction, Parkinson's disease, dizziness, and postural instability, alongside the reference lists of relevant articles. The available evidence suggests the prevalence of vestibular dysfunction-related symptoms in patients with PD and supports the idea that vestibular-targeted therapies may be effective in improving PD symptoms.
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Affiliation(s)
- Meilin Gui
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lingling Lv
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lixia Qin
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
- China National Clinical Research Center on Mental Disorders, Changsha, China
| | - Chunyu Wang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Medical Genetics, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, Changsha, China
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8
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Zoetewei D, Herman T, Ginis P, Palmerini L, Brozgol M, Thumm PC, Ferrari A, Ceulemans E, Decaluwé E, Hausdorff JM, Nieuwboer A. On-Demand Cueing for Freezing of Gait in Parkinson's Disease: A Randomized Controlled Trial. Mov Disord 2024; 39:876-886. [PMID: 38486430 DOI: 10.1002/mds.29762] [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: 11/22/2023] [Revised: 01/24/2024] [Accepted: 02/09/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Cueing can alleviate freezing of gait (FOG) in people with Parkinson's disease (PD), but using the same cues continuously in daily life may compromise effectiveness. Therefore, we developed the DeFOG-system to deliver personalized auditory cues on detection of a FOG episode. OBJECTIVES We aimed to evaluate the effects of DeFOG during a FOG-provoking protocol: (1) after 4 weeks of DeFOG-use in daily life against an active control group; (2) after immediate DeFOG-use (within-group) in different medication states. METHOD In this randomized controlled trial, 63 people with PD and daily FOG were allocated to the DeFOG or active control group. Both groups received feedback on their daily living step counts using the device, but the DeFOG group also received on-demand cueing. Video-rated FOG severity was compared pre- and post-intervention through a FOG-provoking protocol administered at home off and on-medication, but without using DeFOG. Within-group effects were tested by comparing FOG during the protocol with and without DeFOG. RESULTS DeFOG-use during the 4 weeks was similar between groups, but we found no between-group differences in FOG-severity. However, the within-group analysis showed that FOG was alleviated by DeFOG (effect size d = 0.57), regardless of medication state. Combining DeFOG and medication yielded an effect size of d = 0.67. CONCLUSIONS DeFOG reduced FOG considerably in a population of severe freezers both off and on medication. Nonetheless, 4 weeks of DeFOG-use in daily life did not ameliorate FOG during the protocol unless DeFOG was worn. These findings suggest that on-demand cueing is only effective when used, similar to other walking aids. © 2024 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Demi Zoetewei
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Talia Herman
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Pieter Ginis
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Luca Palmerini
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Bologna, Italy
- Health Sciences and Technologies-Interdepartmental Center for Industrial Research (CIRI-SDV), University of Bologna, Bologna, Italy
| | - Marina Brozgol
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Pablo Cornejo Thumm
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Alberto Ferrari
- Department of Engineering "Enzo Ferrari", University of Modena and Reggio Emilia, Modena, Italy
- Science and Technology Park for Medicine, TPM, Democenter Foundation Mirandola, Modena, Italy
| | - Eva Ceulemans
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Eva Decaluwé
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
| | - Jeffrey M Hausdorff
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Israel
- Department of Physical Therapy, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rush Alzheimer's Disease Center and Department of Orthopedic Surgery, Rush University, Chicago, Illinois, USA
| | - Alice Nieuwboer
- KU Leuven, Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), Leuven, Belgium
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9
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Falaki A, Cuadra C, Lewis MM, Prado-Rico JM, Huang X, Latash ML. Multi-muscle synergies in preparation for gait initiation in Parkinson's disease. Clin Neurophysiol 2023; 154:12-24. [PMID: 37524005 DOI: 10.1016/j.clinph.2023.06.022] [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: 03/16/2023] [Revised: 05/20/2023] [Accepted: 06/25/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE We investigated changes in indices of muscle synergies prior to gait initiation and the effects of gaze shift in patients with Parkinson's disease (PD). A long-term objective of the study is to develop a method for quantitative assessment of gait-initiation problems in PD. METHODS PD patients without clinical signs of postural instability and two control groups (age-matched and young) performed a gait initiation task in a self-paced manner, with and without a quick prior gaze shift produced by turning the head. Muscle groups with parallel scaling of activation levels (muscle modes) were identified as factors in the muscle activation space. Synergy index stabilizing center of pressure trajectory in the anterior-posterior and medio-lateral directions (indices of stability) was quantified in the muscle mode space. A drop in the synergy index in preparation to gait initiation (anticipatory synergy adjustment, ASA) was quantified. RESULTS Compared to the control groups, PD patients showed significantly smaller synergy indices and ASA for both directions of the center of pressure shift. Both PD and age-matched controls, but not younger controls, showed detrimental effects of the prior gaze shift on the ASA indices. CONCLUSIONS PD patients without clinically significant posture or gait disorders show impaired stability of the center of pressure and its diminished adjustment during gait initiation. SIGNIFICANCE The indices of stability and ASA may be useful to monitor pre-clinical gait disorders, and lower ASA may be relevant to emergence of freezing of gait in PD.
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Affiliation(s)
- Ali Falaki
- Department of Neurosciences, University of Montreal, Montreal, Quebec, Canada
| | - Cristian Cuadra
- Department of Physical Therapy, Emory University, Atlanta, GA, USA; Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, 7591538 Santiago, Chile
| | - Mechelle M Lewis
- Department of Neurology, Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA, USA; Department of Pharmacology, Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA, USA
| | - Janina M Prado-Rico
- Department of Neurology, Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA, USA
| | - Xuemei Huang
- Department of Neurology, Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA, USA; Department of Pharmacology, Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA, USA; Department of Radiology, Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA, USA; Department of Neurosurgery, Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA, USA; Department of Kinesiology, The Pennsylvania State University, University Park, PA, USA
| | - Mark L Latash
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, USA.
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10
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Roytman S, Paalanen R, Griggs A, David S, Pongmala C, Koeppe RA, Scott PJH, Marusic U, Kanel P, Bohnen NI. Cholinergic system correlates of postural control changes in Parkinson's disease freezers. Brain 2023; 146:3243-3257. [PMID: 37086478 PMCID: PMC10393403 DOI: 10.1093/brain/awad134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/16/2023] [Accepted: 04/06/2023] [Indexed: 04/24/2023] Open
Abstract
Postural instability and freezing of gait are the most debilitating dopamine-refractory motor impairments in advanced stages of Parkinson's disease because of increased risk of falls and poorer quality of life. Recent findings suggest an inability to efficaciously utilize vestibular information during static posturography among people with Parkinson's disease who exhibit freezing of gait, with associated changes in cholinergic system integrity as assessed by vesicular acetylcholine transporter PET. There is a lack of adequate understanding of how postural control varies as a function of available sensory information in patients with Parkinson's disease with freezing of gait. The goal of this cross-sectional study was to examine cerebral cholinergic system changes that associate with inter-sensory postural control processing features as assessed by dynamic computerized posturography and acetylcholinesterase PET. Seventy-five participants with Parkinson's disease, 16 of whom exhibited freezing of gait, underwent computerized posturography on the NeuroCom© Equitest sensory organization test platform, striatal dopamine, and acetylcholinesterase PET scanning. Findings demonstrated that patients with Parkinson's disease with freezing of gait have greater difficulty maintaining balance in the absence of reliable proprioceptive cues as compared to those without freezing of gait [β = 0.28 (0.021, 0.54), P = 0.034], an effect that was independent of disease severity [β = 0.16 (0.062, 0.26), P < 0.01] and age [β = 0.092 (-0.005, 0.19), P = 0.062]. Exploratory voxel-based analysis revealed an association between postural control and right hemispheric cholinergic network related to visual-vestibular integration and self-motion perception. High anti-cholinergic burden predicted postural control impairment in a manner dependent on right hemispheric cortical cholinergic integrity [β = 0.34 (0.065, 0.61), P < 0.01]. Our findings advance the perspective that cortical cholinergic system might play a role in supporting postural control after nigro-striatal dopaminergic losses in Parkinson's disease. Failure of cortex-dependent visual-vestibular integration may impair detection of postural instability in absence of reliable proprioceptive cues. Better understanding of how the cholinergic system plays a role in this process may augur novel treatments and therapeutic interventions to ameliorate debilitating symptoms in patients with advanced Parkinson's disease.
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Affiliation(s)
- Stiven Roytman
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Rebecca Paalanen
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alexis Griggs
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
| | - Simon David
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Chatkaew Pongmala
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Robert A Koeppe
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Peter J H Scott
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Uros Marusic
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Kinesiology Research, Science and Research Centre Koper, 6000 Koper, Slovenia
- Department of Health Sciences, Alma Mater Europaea—ECM, 2000 Maribor, Slovenia
| | - Prabesh Kanel
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nicolaas I Bohnen
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
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11
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Yu X, Wang HJ, Zhen QX, Zhang QR, Yan HJ, Zhen Y, An X, Xi JN, Qie SY, Fang BY. Added forearm weights for gait pattern normalization in patients with Parkinson's disease. J Clin Neurosci 2023; 114:17-24. [PMID: 37276741 DOI: 10.1016/j.jocn.2023.05.025] [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: 03/30/2023] [Revised: 05/11/2023] [Accepted: 05/29/2023] [Indexed: 06/07/2023]
Abstract
Patients with Parkinson's Disease presented gait impairment. Applying additional weights to enhancing sensory input may improve gait impairment. We assumed that gait impairment could be improved when patients walked with additional forearm weights, and the gait improvement was associated with clinical characteristic of Parkinson's Disease. Thirty patients with Parkinson's Disease and 30 age-sex matched controls were recruited. Spatiotemporal and joint kinematics parameters were evaluated by a three-dimensional motion capture system in normal walking and walking with sandbags, respectively. The comparisons of spatiotemporal parameters were analyzed using t-test or nonparametric tests. The comparison of joint kinematic data was analyzed using statistical parametric mapping. The correlation between motor symptom and gait parameters changes was analyzed using Pearson's correlation analysis. During normal walking, patients showed deteriorated gait compared with controls. After applying weights to forearms patients increased cadence (p = 0.004), speed (p < 0.001) and step length (p = 0.048), and decreased stride time (p = 0.003). The hip angles significantly increased during 5%-23% and 87%-100% of gait cycle, while knee angles during 9%-25% and 88%-98% of the gait cycle, and ankle angles in 92%-100% of gait cycle. The gait parameters of patients with forearm-loading showed no significant difference compared with healthy subjects walking normally. The change of gait parameters correlated positively with the axial and tremor severity while correlated negatively with the rigidity sub-score. Patients with tremor dominant subtype also showed greater improvement of speed and step time compared with patients with postural instability/gait difficulty subtype. Applying added weights bilaterally to the forearms of patients can normalize gait patterns. Notably, patients with higher scores on axial and tremor and lower rigidity scores gained more benefits.
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Affiliation(s)
- Xin Yu
- Beijing Rehabilitation Medical College, Capital Medical University, Beijing, China
| | - Hu-Jun Wang
- Rehabilitation Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Qiao-Xia Zhen
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Qiao-Rong Zhang
- Rehabilitation Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Hong-Jiao Yan
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Yi Zhen
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Xia An
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Jia-Ning Xi
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Shu-Yan Qie
- Rehabilitation Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China.
| | - Bo-Yan Fang
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China.
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