Postural reflexes in Parkinson's disease during 'resist' and 'yield' tasks

[Muscle activation times facing to a perturbation in patients with early-stage Parkinson's disease]

OBJECTIVES

Parkinson's disease (PD) generates a high incidence of falls, however, there is little evidence of instabilities in the initial stages. This investigation sought to compare the muscle activation times in patients with initial PD against a postural disturbance vs. a control group.

MATERIALS AND METHODS

The electromyographic activity (EMG) of 10 patients with PD in early stages (61.3 ±3.8 years) and a control group of 10 adults (62.2 ±3.0 year) was evaluated. The participants were subjected to a surface disturbance, which generated a stabilization response. The test was performed under 2conditions: eyes open (OA) v/s eyes closed (OC). Trunk (spinal erector) and lower extremity (soleus, tibialis anterior, femoral biceps, femoral rectus, adductor magnus, gluteus medius) muscle activation time was analyzed using surface EMG.

RESULTS

The PD group showed faster response times compared to the control group in the soleus muscle in OC (P=.04). This same muscle showed differences when comparing OA vs. OC only in the PD group (P=.04), showing a shorter response time in the OC condition. When comparing the spinal erector muscle, the PD group showed slower response times in the OA (P=.02) and OC (P=.04) conditions compared to the control group.

CONCLUSIONS

Muscle activation times show that people with PD respond slower in the trunk muscles, while activation times decrease at the distal level. In the early stages, the slower responses at the trunk level could explain the onset of instability postural in these patients.

Anticipatory Postural Adjustments and Compensatory Postural Responses to Multidirectional Perturbations-Effects of Medication and Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease

BACKGROUND

Postural instability is one of the most restricting motor symptoms for patients with Parkinson's disease (PD). While medication therapy only shows minor effects, it is still unclear whether medication in conjunction with deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves postural stability. Hence, the aim of this study was to investigate whether PD patients treated with medication in conjunction with STN-DBS have superior postural control compared to patients treated with medication alone.

METHODS

Three study groups were tested: PD patients on medication (PD-MED), PD patients on medication and on STN-DBS (PD-MED-DBS), and healthy elderly subjects (HS) as a reference. Postural performance, including anticipatory postural adjustments (APA) prior to perturbation onset and compensatory postural responses (CPR) following multidirectional horizontal perturbations, was analyzed using force plate and electromyography data.

RESULTS

Regardless of the treatment condition, both patient groups showed inadequate APA and CPR with early and pronounced antagonistic muscle co-contractions compared to healthy elderly subjects. Comparing the treatment conditions, study group PD-MED-DBS only showed minor advantages over group PD-MED. In particular, group PD-MED-DBS showed faster postural reflexes and tended to have more physiological co-contraction ratios.

CONCLUSION

medication in conjunction with STN-DBS may have positive effects on the timing and amplitude of postural control.

Impact of pathological conditions on postural reflex latency and adaptability following unpredictable perturbations: A systematic review and meta-analysis

BACKGROUND

Pathological conditions can impair responses to postural perturbations and increase risk of falls.

RESEARCH QUESTION

To what extent are postural reflexes impaired in people with pathological conditions and can exercise interventions shorten postural reflexes?

METHODS

MEDLINE, EMBASE, Scopus, SportDiscus and Web of Science were systematically searched for articles comparing muscle activation onset latency in people with pathological conditions to healthy controls following unpredictable perturbations including the effect of exercise interventions (registration: CRD42020170861).

RESULTS

Fifty-three articles were included for systematic review. Significant delays in muscle activity onset following perturbations were evident in people with multiple sclerosis (n = 7, mean difference [MD]: 22 ms, 95% confidence interval [CI]: 11, 33), stroke (n = 10, MD: 34 ms, 95% CI: 19, 49), diabetes (n = 2, MD: 19 ms, 95% CI: 10, 27), HIV (n = 3, MD: 9 ms, 95% CI: 4, 14), incomplete spinal cord injury (n = 2, MD: 57 ms, 95% CI: 33, 80) and back and knee pain (n = 7, MD: 12 ms, 95% CI: 6, 18), but not in people with Parkinson's disease (n = 10) or cerebellar dysfunction (n = 4). Following exercise interventions, the paretic limb of stroke survivors (n = 3) displayed significantly faster muscle activation onset latency compared to pre-exercise (MD: -13 ms, 95% CI: -24, -4), with no significant changes in Parkinson's disease (n = 3).

CONCLUSIONS

This systematic review demonstrated that postural reflexes are significantly delayed in people with multiple sclerosis (+22 ms), stroke (+34 ms), diabetes (+19 ms), HIV (+9 ms), incomplete spinal cord injury (+57 ms), back and knee pain (+12 ms); pathological conditions characterized by impaired sensation or neural function. In contrast, timing of postural reflexes was not impaired in people with Parkinson's disease and cerebellar dysfunction, confirming the limited involvement of supraspinal structures. The meta-analysis showed exercise interventions can significantly shorten postural reflex latencies in stroke survivors (-14 ms), but more research is needed to confirm this finding and in people with other pathological conditions.

What Can Altered Auditory Feedback Paradigms Tell Us About Vocal Motor Control in Individuals With Voice Disorders?

Purpose

The goal of this review article is to provide a summary of the progression of altered auditory feedback (AAF) as a method to understand the pathophysiology of voice disorders. This review article focuses on populations with voice disorders that have thus far been studied using AAF, including individuals with Parkinson's disease, cerebellar degeneration, hyperfunctional voice disorders, vocal fold paralysis, and laryngeal dystonia. Studies using AAF have found that individuals with Parkinson's disease, cerebellar degeneration, and laryngeal dystonia have hyperactive auditory feedback responses due to differing underlying causes. In persons with PD, the hyperactivity may be a compensatory mechanism for atypically weak feedforward motor control. In individuals with cerebellar degeneration and laryngeal dystonia, the reasons for hyperactivity remain unknown. Individuals with hyperfunctional voice disorders may have auditory-motor integration deficits, suggesting atypical updating of feedforward motor control.

Conclusions

These findings have the potential to provide critical insights to clinicians in selecting the most effective therapy techniques for individuals with voice disorders. Future collaboration between clinicians and researchers with the shared objective of improving AAF as an ecologically feasible and valid tool for clinical assessment may provide more personalized therapy targets for individuals with voice disorders.

Brain Perfusion Mediates the Relationship Between miRNA Levels and Postural Control

Transcriptomics, regional cerebral blood flow (rCBF), and a virtual reality-based spatial motor task were integrated using mediation analysis in a novel demonstration of “imaging omics.” Data collected in National Collegiate Athletic Association (NCAA) Division I football athletes cleared for play before in-season training showed significant relationships in 1) elevated levels of miR-30d and miR-92a to elevated putamen rCBF, 2) elevated putamen rCBF to compromised Balance scores, and 3) compromised Balance scores to elevated microRNA (miRNA) levels. rCBF acted as a consistent mediator variable (Sobel’s test P < 0.05) between abnormal miRNA levels and compromised Balance scores. Given the involvement of these miRNAs in inflammation and immune function and that vascular perfusion is a component of the inflammatory response, these findings support a chronic inflammatory model in these athletes with 11 years of average football exposure. rCBF, a systems biology measure, was necessary for miRNA to affect behavior.

Stabilization of body balance with Light Touch following a mechanical perturbation: Adaption of sway and disruption of right posterior parietal cortex by cTBS

Light touch with an earth-fixed reference point improves balance during quite standing. In our current study, we implemented a paradigm to assess the effects of disrupting the right posterior parietal cortex on dynamic stabilization of body sway with and without Light Touch after a graded, unpredictable mechanical perturbation. We hypothesized that the benefit of Light Touch would be amplified in the more dynamic context of an external perturbation, reducing body sway and muscle activations before, at and after a perturbation. Furthermore, we expected sway stabilization would be impaired following disruption of the right Posterior Parietal Cortex as a result of increased postural stiffness. Thirteen young adults stood blindfolded in Tandem-Romberg stance on a force plate and were required either to keep light fingertip contact to an earth-fixed reference point or to stand without fingertip contact. During every trial, a robotic arm pushed a participant's right shoulder in medio-lateral direction. The testing consisted of 4 blocks before TMS stimulation and 8 blocks after, which alternated between Light Touch and No Touch conditions. In summary, we found a strong effect of Light Touch, which resulted in improved stability following a perturbation. Light Touch decreased the immediate sway response, steady state sway following re-stabilization, as well as muscle activity of the Tibialis Anterior. Furthermore, we saw gradual decrease of muscle activity over time, which indicates an adaptive process following exposure to repetitive trials of perturbations. We were not able to confirm our hypothesis that disruption of the rPPC leads to increased postural stiffness. However, after disruption of the rPPC, muscle activity of the Tibialis Anterior is decreased more compared to sham. We conclude that rPPC disruption enhanced the intra-session adaptation to the disturbing effects of the perturbation.

A comparison of the relationship between manual dexterity and postural control in young and older individuals with Parkinson's disease

The motor symptoms of Parkinson's disease (PD) cause deterioration in manual dexterity. This deterioration affects independence in activities of daily living negatively. The loss of postural control, which occurs more frequently with disease progression, restricts physical functions and reduces mobility in patients with PD. Impaired postural control may affect distal mobility of an individual. The aim of this study was to investigate postural control and manual dexterity in individuals ≤ 65 and >65 years with PD and analyze the relationship between these variables according to age. Sixty-six individuals with PD participated in the study. The participants were categorized according to age (n = 29 for 65 years of age or younger and n = 37 for older). Manual dexterity (Dominant and Non-dominant hand) was assessed by the Nine Hole Peg Test (NHPT). Postural control was evaluated by the Limit of Stability Test (LoS) using a computerized balance measuring instrument. There was no statistically significant difference between the age groups on the combined dependent variables after controlling for disability, gender, weight, and height; F(7, 54) = 0.804, p = 0.587. Only LoS-Maximum Excursion was higher in the individuals ≤ 65 years (p = 0.035). Significant correlations were found between NHPT-Dominant and LoS-Reaction Time, LoS-Maximum Excursion; NHPT-Non-dominant and LoS-Reaction Time, LoS-Endpoint Excursion, LoS-Maximum Excursion in the older group (p < 0.05). There was no difference manual dexterity and postural control according to age except for LoS-Maximum Excursion. LoS-Maximum Excursion was higher in the young group. The manual dexterity was associated with postural control in individuals over 65 years of age with PD; however, not associated in younger individuals.

Visual field motion during a body pull affects compensatory standing and stepping responses

KEY POINTS

It is unclear whether the visual input that accompanies a perturbation of a standing person can affect whether a recovery step is taken. Visual motion speeds were manipulated during unexpected forward and backward shoulder pulls. Visual motion that appeared slower than actual body motion reduced the initial in-place resistance to the perturbation. As a result of the modulation of the in-place response, less pull force was needed to trigger a step when visual velocity appeared slower than normal. The visuomotor postural response occurred earlier and was larger when the full-field visual input was paired with a mechanical perturbation.

ABSTRACT

The present study aimed to determine how visual motion evoked by an upper body perturbation during standing affects compensatory postural responses. This was investigated by rotating the visual field forwards or backwards about the ankle, time-locked to a forwards or backwards shoulder pull. Kinematic, kinetic and electromyographic responses were recorded to a range of pull forces over 160 trials in 12 healthy adults (mean ± SD = 31 ± 5.8 years). Stepping threshold forces and in-place postural responses were compared between conditions. When the visual field moved in the same direction as the pull, so that the apparent velocity of the body was reduced (SLOW condition), the pull-force required to induce a step was less than when the visual field either rotated in the opposite direction (FAST) or was unaltered (NATURAL). For in-place responses, the body was displaced further in the direction of the pull in the SLOW condition. This was the result of a reduction in the resistive force from lower leg muscles 130 ms after the visual motion onset. In trials with no pull, the visual motion induced postural responses that were later (290 ms) and had smaller amplitudes compared to when visual motion is paired with an unexpected perturbation of the body. The results suggest that the apparent speed of the visual environment during a perturbation does influence whether a compensatory step is taken, not via a direct effect on the decision to step but by modulating the initial in-place response.

Relationship between Gait Parameters and Postural Stability in Early and Late Parkinson's Disease and Visual Feedback-Based Balance Training Effects

BACKGROUND

Gait disorders or postural instability has been done before. However, lack of reviews has addressed the relation between gait and postural stability in Parkinson's disease (PD).

AIM

The aim was to evaluate the relation between gait parameters and postural stability in early and late stages of PD.

MATERIALS AND METHODS

The forty-one idiopathic PD patients were divided into two groups into a group (A) considered as early PD and group (B) considered as late ambulant PD. They were evaluated for postural stability by computerised dynamic posturography (CDP) device and gait analysis using an 8 m-camera Vicon 612 data capturing system set.

RESULTS

There was a statistically significant improvement of composite equilibrium score, the composite latency of motor response, walking speed and cadence after treatment as compared to before training (p < 0.05) in early PD. However, in the late PD, there was a non-significant change of previous parameters after treatment as compared to before training (p > 0.05). There was a significant correlation between UPDRS motor part score, walking speed and composite equilibrium score after training in early PD (p > 0.05).

CONCLUSIONS

Both gait analysis and CDP are important quantitative assessment tools of gait and posture instability.

Validity of the microsoft kinect system in assessment of compensatory stepping behavior during standing and treadmill walking

Background

Rapid compensatory stepping plays an important role in preventing falls when balance is lost; however, these responses cannot be accurately quantified in the clinic. The Microsoft Kinect™ system provides real-time anatomical landmark position data in three dimensions (3D), which may bridge this gap.

Methods

Compensatory stepping reactions were evoked in 8 young adults by a sudden platform horizontal motion on which the subject stood or walked on a treadmill. The movements were recorded with both a 3D-APAS motion capture and Microsoft Kinect™ systems. The outcome measures consisted of compensatory step times (milliseconds) and length (centimeters). The average values of two standing and walking trials for Microsoft Kinect™ and the 3D-APAS systems were compared using t-test, Pearson’s correlation, Altman-bland plots, and the average difference of root mean square error (RMSE) of joint position.

Results

The Microsoft Kinect™ had high correlations for the compensatory step times (r = 0.75–0.78, p = 0.04) during standing and moderate correlations for walking (r = 0.53–0.63, p = 0.05). The step length, however had a very high correlations for both standing and walking (r > 0.97, p = 0.01). The RMSE showed acceptable differences during the perturbation trials with smallest relative error in anterior-posterior direction (2-3%) and the highest in the vertical direction (11–13%). No systematic bias were evident in the Bland and Altman graphs.

Conclusions

The Microsoft Kinect™ system provides comparable data to a video-based 3D motion analysis system when assessing step length and less accurate but still clinically acceptable for step times during balance recovery when balance is lost and fall is initiated.

Postural instability in Parkinson Disease: to step or not to step

Postural instability is a key feature of Parkinson Disease that is associated with falls and morbidity. We designed a pull apparatus to quantitatively measure the force needed to pull subjects off-balance. Thirteen Controls and eight individuals with Parkinson Disease (PD) were evaluated. All individuals with PD reported subjective symptoms of postural instability and were symptomatic for approximately 9.4years when tested. No significant differences were found between Controls and PD subjects in the magnitude of force required to pull them off-balance. None of the Controls fell and all took a step into the direction of pull to maintain their balance. 59% of the time PD subjects fell because they did not take a step in the direction of pull to maintain their center of mass (COM) over their feet, thus indicating a deficiency in postural reflexes. If they fell on the first pull, PD subjects did not show a learning effect when pulled multiple times in the same direction. The utility of the Pull Test to detect postural instability is related to the subject's behavioral response, not the force needed to pull them off balance. Our findings may also help explain certain features of the PD gait as an attempt by subjects to avoid postural instability by not placing their COM in gravitationally unstable positions.

Fiber-based wearable electronics: a review of materials, fabrication, devices, and applications

Fiber-based structures are highly desirable for wearable electronics that are expected to be light-weight, long-lasting, flexible, and conformable. Many fibrous structures have been manufactured by well-established lost-effective textile processing technologies, normally at ambient conditions. The advancement of nanotechnology has made it feasible to build electronic devices directly on the surface or inside of single fibers, which have typical thickness of several to tens microns. However, imparting electronic functions to porous, highly deformable and three-dimensional fiber assemblies and maintaining them during wear represent great challenges from both views of fundamental understanding and practical implementation. This article attempts to critically review the current state-of-arts with respect to materials, fabrication techniques, and structural design of devices as well as applications of the fiber-based wearable electronic products. In addition, this review elaborates the performance requirements of the fiber-based wearable electronic products, especially regarding the correlation among materials, fiber/textile structures and electronic as well as mechanical functionalities of fiber-based electronic devices. Finally, discussions will be presented regarding to limitations of current materials, fabrication techniques, devices concerning manufacturability and performance as well as scientific understanding that must be improved prior to their wide adoption.

Postural inflexibility in PD: does it affect compensatory stepping?

Parkinson's disease (PD) impairs the ability to shape postural responses to contextual factors. It is unknown whether such inflexibility pertains to compensatory steps to overcome balance perturbations. Participants were instructed to recover balance in response to a platform translation. A step was necessary to recover balance when the translation was large, whereas a feet-in-place (FiP) response was sufficient when the translation was small (i.e. no step). We compared step trials that required a switch away from the current postural set (switch trials: step trials that were preceded by FiP trials) with non-switch trials (i.e. step trials were preceded by identical step trials). 51 PD patients (59 ± 7 years) were compared with 22 healthy controls (60 ± 6 years). In a second analysis, we compared a subgroup of 14 freezers (PD-FOG) with a subgroup of 14 non-freezers (PD-noFOG; matched for age, gender and disease severity). Compared to non-switch trials, switch trials resulted in poorer step execution and more steps needed to recover balance. These switching effects were similar in PD patients and controls, and in PD-FOG and PD-noFOG patients. Overall, PD patients demonstrated poorer stepping performance than controls. PD-FOG had a worse performance than PD-noFOG. Moreover, PD patients, and particularly PD-FOG patients, were less able to improve step performance with repetitive step trials, in contrast to controls. Thus, there was no PD-related deficit to switch to an alternative response strategy, neither in patients with FOG nor in patients without FOG. Difficulty to adapt the step trial-by-trial might have contributed to the absence of switch deficits in PD.

Postural instability in patients with Parkinson's disease. Epidemiology, pathophysiology and management

Postural instability is one of the cardinal signs in Parkinson's disease (PD). It can be present even at diagnosis, but becomes more prevalent and worsens with disease progression. It represents one of the most disabling symptoms in the advanced stages of the disease, as it is associated with increased falls and loss of independence. Clinical and posturographic studies have contributed to significant advances in unravelling the complex pathophysiology of postural instability in patients with PD, but it still remains yet to be fully clarified, partly due to the difficulty in distinguishing between the disease process and the compensatory mechanisms, but also due to the fact that non-standardized techniques are used to measure balance and postural instability. There is increasing evidence that physical therapy, especially highly challenging balance exercises, can improve postural stability and reduce the risk of falls, although the long-term effects of physical therapy interventions on postural stability need to be explored given the progressive nature of PD. Pharmacotherapy with dopaminergic medications can provide significant improvements in postural instability in early- to mid-stage PD but the effects tend to wane with time consistent with spread of the disease process to non-dopaminergic pathways in advanced PD. Donepezil has been associated with a reduced risk of falls and methylphenidate has shown potential benefit against freezing of gait, but the results are yet to be replicated in large randomized studies. Surgical treatments, including lesioning and deep brain stimulation surgery targeting the subthalamic nucleus and the globus pallidus internus, tend to only provide modest benefit for postural instability. New surgical targets such as the pedunculopontine nucleus have emerged as a potential specific therapy for postural instability and gait disorder but remain experimental.

Keeping your balance while balancing a cylinder: interaction between postural and voluntary goals

The present study investigated whether postural responses are influenced by the stability constraint of a voluntary, manual task. We also examined how task constraint and first experience (the condition with which the participants started the experiment) influence the kinematic strategies used to simultaneously accomplish a postural response and a voluntary task. Twelve healthy, older adults were perturbed during standing, while holding a tray with a cylinder placed with the flat side down (low constraint, LC) or with the rolling, round side down (high constraint, HC). Central set changed according to the task constraint, as shown by a higher magnitude of both the gastrocnemius and tibialis anterior muscle activation bursts in the HC than in the LC condition. This increase in muscle activation was not reflected, however, in changes in the center of pressure or center of mass displacement. Task constraint influenced the peak shoulder flexion for the voluntary tray task but not the peak hip flexion for the postural task. In contrast, first experience influenced the peak hip flexion but not the peak shoulder flexion. These results suggest an interaction between two separate control mechanisms for automatic postural responses and voluntary stabilization tasks.

First trial reactions and habituation rates over successive balance perturbations in Parkinson's disease

BACKGROUND

Balance control in Parkinson's disease is often studied using dynamic posturography, typically with serial identical balance perturbations. Because subjects can learn from the first trial, the magnitude of balance reactions rapidly habituates during subsequent trials. Changes in this habituation rate might yield a clinically useful marker. We studied balance reactions in Parkinson's disease using posturography, specifically focusing on the responses to the first, fully unpractised balance disturbance, and on the subsequent habituation rates.

METHODS

Eight Parkinson patients and eight age- and gender-matched controls received eight consecutive toe-up rotations of a support-surface. Balance reactions were measured with a motion analysis system and converted to centre of mass displacements (primary outcome).

RESULTS

Mean centre of mass displacement during the first trial was 51% greater in patients than controls (P=0.019), due to excessive trunk flexion and greater ankle plantar-flexion. However, habituated trials were comparable in both groups. Patients also habituated slower: controls were fully habituated at trial 2, whereas habituation in patients required up to five trials (P=0.004). The number of near-falls during the first trial was significantly correlated with centre of mass displacement during the first trial and with habituation rate.

CONCLUSIONS

Higher first trial reactions and a slow habituation rate discriminated Parkinson's patients from controls, but habituated trials did not. Further work should demonstrate whether this also applies to clinical balance tests, such as the pull test, and whether repeated delivery of such tests offers better diagnostic value for evaluating fall risks in parkinsonian patients.

The effects of subthalamic and pallidal deep brain stimulation on postural responses in patients with Parkinson disease

OBJECT

The effect of deep brain stimulation (DBS) for Parkinson disease (PD) on balance is unclear. The goal of this study was to investigate how automatic postural responses (APRs) were affected in patients randomized to either subthalamic nucleus (STN) or globus pallidus internus (GPi) surgery.

METHODS

The authors tested 24 patients with PD who underwent bilateral DBS, 9 control patients with PD who did not undergo DBS, and 17 age-matched control volunteers. The electrode placement site was randomized and blinded to the patients and to the experimenters. Kinematic, kinetic, and electromyographic recordings of postural responses to backward disequilibrium via forward translations of the standing surface were recorded in the week prior to surgery while the patients were off (OFF) and on (ON) antiparkinsonian medication (levodopa), and then 6 months after surgery in 4 conditions: 1) off medication with DBS switched off (OFF/OFF); 2) off medication with DBS on (DBS); 3) on medication with DBS off (DOPA); and 4) with both medication and DBS on (DBS+DOPA). Stability of the automatic postural response (APR) was measured as the difference between the displacement of the center of pressure and the projected location of the center of body mass.

RESULTS

Patients with PD had worse APR stability than controls. Turning the DBS on at either site improved APR stability compared with the postoperative OFF condition by lengthening the tibialis response, whereas medication did not show an appreciable effect. The STN group had worse APR stability in their best functional state (DBS+DOPA) 6 months after the DBS procedure compared with their best functional state (ON levodopa) before the DBS procedure. In contrast, the GPi group and the PD control group showed no change over 6 months. The APR stability impairment in the STN group was associated with smaller tibialis response amplitudes, but there was no change in response latency or coactivation with gastrocnemius.

CONCLUSIONS

Turning the DBS current on improved APR stability for both STN and GPi sites. However, there was a detrimental DBS procedural effect for the STN group, and this effect was greater than the benefit of the stimulating current, making overall APR stability functionally worse after surgery for the STN group.

The long-latency reflex is composed of at least two functionally independent processes

The nervous system counters mechanical perturbations applied to the arm with a stereotypical sequence of muscle activity, starting with the short-latency stretch reflex and ending with a voluntary response. Occurring between these two events is the enigmatic long-latency reflex. Although researchers have been fascinated by the long-latency reflex for over 60 years, some of the most basic questions about this response remain unresolved and often debated. In the present study we help resolve one such question by providing clear evidence that the human long-latency reflex during a naturalistic motor task is not a single functional response; rather, it appears to reflect the output of (at least) two functionally independent processes that overlap in time and sum linearly. One of these functional components shares an important attribute of the short-latency reflex (i.e., automatic gain scaling, sensitivity to background load), and the other shares a defining feature of voluntary control (i.e., task dependency, sensitivity to goal target position). We further show that the task-dependent component of long-latency activity reflects a feedback control process rather than the simplest triggered reaction to a mechanical stimulus.

REM sleep behavior disorder is not linked to postural instability and gait dysfunction in Parkinson

To evaluate a potential association of REM-sleep behavior disorder (RBD) with gait and postural impairment in Parkinson's disease (PD). Gait difficulties and postural impairment are frequent in PD and are a major cause of disability. Animal studies indicate a key role of the pedunculopontine nucleus (PPN) in gait, postural control, and REM sleep, and also in the pathophysiology of RBD. In humans, such an association has not been investigated. Twenty-six patients with mild-to-moderate PD (13 with polysomnography confirmed and 13 with excluded RBD), and 20 age-matched healthy controls were prospectively investigated. Gait assessment on a treadmill, and static and dynamic posturography were performed. PD patients with RBD do not differ from those without RBD in gait and postural control. Greater severity of PD or prevalence of gait and postural disturbances in the presence of RBD were not found. RBD was not associated with any particular motor phenotype. We found no association of RBD with gait disturbances and postural impairment. Human gait and postural control and RBD appear to depend upon different neuronal circuits.

Modulation of cutaneous reflexes from the foot during gait in Parkinson's disease

Normal gait is characterized by a phase-dependent modulation of cutaneous reflexes. The role of the basal ganglia in regulating these reflexes is largely unknown. Therefore cutaneous reflex responses from the skin of the foot were studied during walking of patients with mild to moderate Parkinson's disease (PD). The reflex responses were elicited by stimulation of the sural nerve of the most affected leg. The responses were studied in the biceps femoris (BF) and tibialis anterior (TA) of both legs. The latencies, durations, and phase-dependent modulation patterns of the responses were mostly comparable with those observed in healthy subjects. However, on average the amplitude of the responses in the ipsilateral and contralateral BF was respectively 1.4- and 5-fold larger for the PD patients than that for the healthy subjects. This increase was mostly seen throughout the whole step cycle. However, in some PD patients the crossed BF responses were very large during the contralateral swing phase. In such cases the increase in crossed reflexes sometimes reflected premotoneuronal gating since it was not always due to increased background activation in that period. Fast activation of contralateral BF reflexes is known to occur in conjunction with ipsilateral perturbations when there is a threat to stability. It is concluded that cutaneous reflexes are facilitated in PD but that some of the increase in reflexes in BF may be indirectly related to unsteady gait and to perceived instability.

Coordination of grasping and walking in Parkinson's disease

Studies on grasp control underlying manual dexterity in people with Parkinson disease (PD) suggest that anticipatory grasp control is mainly unaffected during discrete tasks using simple two-digit grasp. Nevertheless, impaired hand function during daily activities is one of the most disabling symptoms of PD. As many daily grasping activities occur during functional movements involving the whole body, impairments in anticipatory grasp control might emerge during a continuous dynamic task such as object transport during walking. In this case, grasp control must be coordinated along with multiple body segments. The present study investigated the effect of PD on anticipatory grasp control and intersegmental coordination during walking with a hand-held object. Nine individuals with idiopathic PD (tested OFF and ON medication) and nine healthy age-matched controls carried a grip instrument between their right thumb and index finger during self-paced and fast walking. Although the amplitude of grip forces was higher in standing and walking for subjects with PD, both subjects with PD and control subjects coupled grip and inertial force changes in an anticipatory fashion while walking. However, gait-induced motions of the object relative to that of the trunk (i.e., dampening) was reduced in subjects with PD. Medication increased the dampening in all subjects with PD. We suggest that these differences are associated with impairments in intersegmental coordination.

Postural feedback scaling deficits in Parkinson's disease

Many differences in postural responses have been associated with age and Parkinson's disease (PD), but until now there has been no quantitative model to explain these differences. We developed a feedback control model of body dynamics that could reproduce the postural responses of young subjects, elderly subjects, and subjects with PD, and we investigated whether the postural impairments of subjects with PD can be described as an abnormal scaling of postural feedback gain. Feedback gains quantify how the nervous system generates compensatory joint torques based on kinematic responses. Seven subjects in each group experienced forward postural perturbations to seven different backward support surface translations ranging from 3- to 15-cm amplitudes and with a constant duration of 275 ms. Ground reaction forces and joint kinematics were measured to obtain joint torques from inverse dynamics. A full-state feedback controller with a two-segment body dynamic model was used to simulate joint kinematics and kinetics in response to perturbations. Results showed that all three subject groups gradually scaled postural feedback gains as a function of perturbation amplitudes, and the scaling started even before the maximum allowable ankle torque was reached. This result implies that the nervous system takes body dynamics into account and adjusts postural feedback gains to accommodate biomechanical constraints. PD subjects showed significantly smaller than normal ankle feedback gain with low scaling and larger hip feedback gain, which led to an early violation of the flat-foot constraint and unusually small (bradykinetic) postural responses. Our postural feedback control model quantitatively described the postural abnormality of the patients with PD as abnormal feedback gains and reduced ability to modify postural feedback gain with changes in postural challenge.

Postural disorders in Parkinson's disease

Posture is often affected in Parkinson's disease. Postural abnormalities belong to the motor axial involvement. Generally, postural dysfunction induces clinical impairment at the latest stages of the disease, except in late-onset idiopathic Parkinson's disease and in atypical parkinsonian syndromes. Posture may be affected in its orientation component (stooped posture, camptocormia, Pisa syndrome) or in its balance component (loss of postural reflexes). Overall, postural impairment is poorly improved by levodopa, which implies that it is unlikely due to the nigrostriatal dopaminergic denervation. Several methods of investigation have been proposed but are generally not available in clinical practice. Medical treatment and deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus pars interna are less efficient on axial than on distal motor signs. The pedonculopontine nucleus seems promising as a new target for DBS in combination with the subthalamic nucleus. Physical therapy is, in most cases, the best way to improve postural dysfunction.

The control of upright stance in young, elderly and persons with Parkinson's disease

The aims of the present study are twofold: (1) to compare the postural control mechanisms of young and elderly people as well as in Parkinson's disease (PD) patients during quiet standing and (2) to assess the impact of a stooped posture on these mechanisms. All subjects were required to maintain both a side-by-side and a 45 degrees foot position. Elderly subjects performed a third condition where they were requested to mimic the stooped posture as adopted by PD subjects. The net centre of pressure (COP(net)) and centre of mass (COM) profiles in the anterior/posterior (A/P) and medial/lateral (M/L) planes were analyzed. The COP(net) signal was recorded from two force plates and was categorized in two mechanisms: an ankle mechanism (COP(c)) and a load/unload hip mechanism (COP(v)). The results showed similar postural control mechanisms in young, elderly and PD subjects. When the feet were side-by-side, the COP(net) was controlled by the ankle plantar/dorsiflexors (COP(c)) in the A/P direction, while by the hip abductor/adductors (COP(v)) controlled in the M/L direction. When the feet were in the 45 degrees position, both the ankle and hip mechanisms contributed to the COP(net). However, the PD subjects showed significant smaller RMS amplitudes compared to the elderly people in the 45 degrees foot position and in the stooped posture. These findings suggest that PD subjects resort to a stiffening strategy to control their balance in postural tasks that imply a mixed control (ankle and hip mechanisms) but have adapted to their stooped posture.

Postural sway and falls in Parkinson's disease: A regression approach

A population-based study was designed to evaluate the clinical associates of postural sway and to identify the risk factors for falls in Parkinson's disease (PD). From a total population of 205,000 inhabitants, 215 PD patients were identified of which 120 home-dwelling cases were finally included in the study. Medical data were collected and patients were clinically examined and tested for static balance using an inclinometric device. Recent falls occurred in 40 (33%) of the subjects and 27 (23%) subjects were recurrent fallers. The fallers had a significantly larger sway area (P = 0.021) and a larger maximum deflection in anterior-posterior (P = 0.016) and lateral directions (P = 0.006) than the nonfallers. A significant correlation was found between the sway measures and the UPDRS total score, motor subcore and UPDRS "bradykinesia" item. A higher UPDRS total score (OR: 1.04, 95% CI: 1.01-1.07) and an increased sway area (OR: 1.25, 95% CI: 1.02-1.54) were independent risk factors for recent falling in PD. In addition, the duration and severity of PD, antiparkinsonian medication, recent falling and the use of a walking aid were associated with increased sway measures. The results can be used to identify PD patients who are at a risk of falling. Both antiparkinsonian medication and nonmedical treatment should be optimized to reduce falls in PD.

Incorporating voluntary knee flexion into nonanticipatory balance corrections

Knee movements play a critical role in most balance corrections. Loss of knee flexibility may cause postural instability. Conversely, trained voluntary knee flexions executed during balance corrections might help to overcome balance deficits. We examined whether bilateral knee flexion could be added to automatic balance corrections generated by sudden balance perturbations. We investigated how this could be achieved and whether it improved or worsened balance control. Twenty-four healthy subjects participated in three different test conditions, in which they had to flex their knees following an auditory cue (VOLUNTARY condition), had to restore their balance in response to multidirectional rotations of a support surface (REACTIVE condition), or the combination of these two (COMBINED condition). A new variable set (PREDICTED), calculated as the mathematical sum of VOLUNTARY and REACTIVE, was compared with the COMBINED variable set. COMBINED responses following forward rotations were close to PREDICTED, or greater, suggesting adequate integration of knee flexion into the automatic balance reactions. For backward rotations, the COMBINED condition resulted in several near-falls, and this was generally associated with smaller knee flexion and smaller EMG responses. Subjects compensated by using greater trunk flexion and arm movements. Activity in several muscles displayed earlier onsets for the COMBINED condition following backward rotations. We conclude that healthy adults can incorporate voluntary knee flexion into their automatic balance corrections and that this depends on the direction of the postural perturbation. These findings highlight the flexibility of the human balance repertoire and underscore both the advantages and limitations of using trained voluntary movements to aid balance corrections in man.

Cortical control of postural responses

This article reviews the evidence for cortical involvement in shaping postural responses evoked by external postural perturbations. Although responses to postural perturbations occur more quickly than the fastest voluntary movements, they have longer latencies than spinal stretch reflexes, suggesting greater potential for modification by the cortex. Postural responses include short, medium and long latency components of muscle activation with increasing involvement of the cerebral cortex as latencies increase. Evidence suggests that the cortex is also involved in changing postural responses with alterations in cognitive state, initial sensory-motor conditions, prior experience, and prior warning of a perturbation, all representing changes in "central set." Studies suggest that the cerebellar-cortical loop is responsible for adapting postural responses based on prior experience and the basal ganglia-cortical loop is responsible for pre-selecting and optimizing postural responses based on current context. Thus, the cerebral cortex likely influences longer latency postural responses both directly via corticospinal loops and shorter latency postural responses indirectly via communication with the brainstem centers that harbor the synergies for postural responses, thereby providing both speed and flexibility for pre-selecting and modifying environmentally appropriate responses to a loss of balance.

Effects of random whole-body vibration on postural control in Parkinson's disease

We investigated spontaneous effects of random whole-body vibration (rWBV) on postural control in Parkinsonian subjects. Effects were examined in biomechanical tests from a total of 52 patients divided equally into one experimental and one control group. Postural control was tested pre- and post-treatment in two standardized conditions (narrow standing and tandem standing). The intervention was based on rWBV (ŷ: 3 mm, f: 6 Hz 1 Hz/sec) consisting of 5 series lasting 60 seconds each. The main findings from this study were that (1) rWBV can improve postural stability in Parkinson's disease (PD) spontaneously (2) these effects depend on the test condition. Based on the results of this study, rWBV can be regarded as an additional device in physical therapy in PD.

Postural reactions to soleus muscle vibration in Parkinson's disease: scaling deteriorates as disease progresses

Previous research has shown that Parkinson's disease (PD) patients, especially those with postural instability, respond hyperactively to visual, vestibular, and neck proprioceptive sensory manipulation. To determine if this impairment of the sensory information scaling holds true for the lower leg proprioceptive system, we studied postural responses to mechanical vibration (which affects the muscle spindle Ia afferents) applied to the soleus muscles of PD subjects and healthy controls. Early-stage and advanced-stage PD patients as well as age-matched control subjects participated. Each group comprised 11 subjects. Nine pulses of 3-s long vibration were applied randomly to both soleus muscles while subjects kept their eyes closed. Postural responses to these stimuli were measured by static posturography. The effect of dopaminergic medication was established by testing patients in both ON and OFF treatment phases. There was no intergroup difference in the pattern or latencies of responses. However, the amplitudes were significantly larger in advanced PD patients; controls did not differ from early-stage PD patients. Dopaminergic medication had no significant effect on any of the measures. The scaling of postural reactions triggered by lower leg proprioception is disturbed in advanced PD. Neither afferent proprioceptive deficits nor inaccurate timing is involved. This study gives further evidence for the generalized impairment of the scaling of postural responses evoked whenever there is a sudden change of sensory conditions, as occurs with the progression of PD. Such impairment could play a significant role in the pathophysiology of postural instability and falls in PD patients.

Evolution of postural stability after subthalamic nucleus stimulation in Parkinson’s disease: a combined clinical and posturometric study

OBJECTIVES

The occurrence of postural and balance disorders is a frequent feature in advanced forms of Parkinson's disease (PD). However, the pathological substrate of these disturbances is poorly understood.

METHODS

In the present work, we investigated the evolution of posturometric parameters [center of pressure (CoP) displacement and CoP area] and axial scores between the pre-operative period and 3 months post-operative in seven PD patients who underwent bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN).

RESULTS

After surgery, the patients leaned backwards much more regardless of the STN stimulation, suggesting that surgery could have a deleterious effect on postural adaptation. During the post-operative period, the improvement in axial and postural scores was similar under levodopatherapy and DBS. On the other hand, DBS of the STN significantly reduced the CoP displacement and the CoP area, whereas levodopatherapy tended only to reduce the CoP displacement and to increase the CoP area significantly.

CONCLUSIONS

These data suggest that DBS of the STN and levodopa do not act on the same neurological systems involved in posture regulation. DBS of the STN could improve posture via a direct effect on the pedunculopontine nucleus, which is known to be involved in posture regulation.

Degradation of postural control system as a consequence of Parkinson's disease and ageing

In this study we have shown how Parkinson's disease and ageing affect the postural control system. Our investigation of that system has involved analysis of quiet-standing center of pressure (COP) trajectories. Using the method derived from Langevin equation, we have found disease-specific and age-specific changes in the dynamics of the COP. These findings were obtained from a comparison of the diffusion matrix, the friction coefficient and the matrix of the fluctuation strength for healthy young, healthy elderly and parkinsonian (elderly) subjects under eyes-open and eyes-closed conditions. Especially the analysis of the friction coefficient and the matrix of the fluctuation strength have allowed the more detailed study of the postural control system of the parkinsonian and elderly subjects. We have found that the healthy elderly as well as parkinsonian subjects exhibit larger level of the muscular stochastic activity, compared to the young subjects. Furthermore, closure their eyes causes further increment of that activity. We have also shown that for the healthy elderly subjects a compensating mechanism, which can be described by the friction coefficient, acts under eyes-closed conditions, whereas for parkinsonian subjects this mechanism was not observed. Thus, the increase of the muscular activity is an age-specific indicator, whereas the absence of the compensation of that increase is a disease-specific indicator.

Control of support limb muscles in recovery after tripping in young and older subjects

Older people fall more often after tripping than young people due to a slower development of mechanical responses. This might be due to age-related changes in muscle properties, but also to changes in motor control. The purpose of the present study was to determine whether (a) timing and sequencing of muscle activation and (b) the magnitude and rate of development of muscle activation in recovery after a trip differs between young and older subjects. We focused on the support limb, as it contributes to recovery after tripping by counteracting the forward angular momentum. Ten young (25 years) and seven older (68 years) men and women walked over a platform and were tripped several times at different points in the gait cycle. Kinematics and EMG of the support limb muscles were measured. After tripping, rapid EMG responses (60-80 ms) were observed in hamstring and triceps surae muscles in both young and older subjects. A slightly increased delay (11 ms) was found only in the soleus muscle of the older subjects. The muscle activity patterns (timing and sequencing) were similar in young and older subjects, but the magnitude and rate of development of muscle activity were significantly lower in older subjects. Especially the lower rate of development of muscle activation in the support limb of older subjects is likely to reduce the rate of force generation, which can contribute to inadequate recovery responses and falls.

Deficits in adaptive upper limb control in response to trunk perturbations in Parkinson's disease

The ability of patients with Parkinson's disease (PD) to compensate for unexpected perturbations remains relatively unexplored. To address this issue PD subjects were required to compensate at the arm for an unexpected mechanical perturbation of the trunk while performing a trunk-assisted reach. Twelve healthy and nine PD subjects (off medication) performed trunk-assisted reaching movements without vision or knowledge of results to a remembered target in the ipsilateral (T1) or contralateral (T2) workspace. On 60% of the trials trunk motion was unrestrained (free condition). On the remaining 40% of randomly selected trials trunk motion was arrested at movement onset (blocked condition). If subjects appropriately changed arm joint angles to compensate for the trunk arrest, there should be spatial and temporal invariance in the hand trajectories and in the endpoint errors across conditions. The control group successfully changed their arm configuration in a context-dependent manner which resulted in invariant hand trajectory profiles across the free and blocked conditions. More so, they initiated these changes rapidly after the trunk perturbation (group mean 70 ms). Some PD subjects were unable to maintain invariant hand paths and movement errors across conditions. Their hand velocity profiles were also more variable relative to those of the healthy subjects in the blocked-trunk trials but not in the free-trunk trials. Furthermore, the latency of compensatory changes in arm joint angles in movements toward T1 was longer in the PD group (group mean 153 ms). Finally, PD subjects' arm and trunk were desynchronized at movement onset, confirming our previous findings and consistent with PD patients' known problems in the sequential or parallel generation of different movement components. The findings that individual PD subjects were unsuccessful or delayed in producing context-dependent responses at the arm to unexpected perturbations of the trunk suggests that the basal ganglia are important nodes in the organization of adaptive behavior.

Postural muscle responses to multidirectional translations in patients with Parkinson's disease

The postural adaptation impairments of patients with Parkinson's disease (PD) suggest that the basal ganglia may be important for quickly modifying muscle activation patterns when the direction of perturbation or stance conditions suddenly change. It is unknown whether their particular instability to backward postural perturbations is due to specific abnormalities of parkinsonian postural muscle synergies in that direction and not present in other directions. In the present study, we test this hypothesis by comparing the patterns of leg and trunk muscle activation in 13 subjects with PD and 13 control subjects in response to eight randomly presented directions of horizontal surface translations while standing with either narrow or wide stance. The direction of maximum activation for each muscle was similar for PD and control subjects, suggesting that the basal ganglia is not critical for programming externally triggered postural synergies. However, antagonist muscle activation was earlier and larger in PD than in control subjects, resulting in coactivation. PD subjects also did not increase the magnitude of muscle activation as much as did control subjects when changing from wide to narrow stance. These results are consistent with the hypothesis that PD results in an inability to shape the pattern and magnitude of postural muscle responses for changes in perturbation direction and in stance position.

Parkinson's disease and anaesthesia

Parkinson's disease is an increasingly common disease of elderly patients who present a particular anaesthetic challenge. This review explores the epidemiology, aetiology, pathogenesis, and pathophysiology of the condition, particularly the possible role of genetic factors. The clinical features are described in detail and recent advances in medical management are highlighted. Controversies surrounding the use of the newer drugs and possible advances in neurosurgical interventions are discussed. Particular anaesthetic problems in patients with Parkinson's disease are respiratory, cardiovascular, and neurological. Potential drug interactions are described and recommendations are made about suitable anaesthetic techniques.

Analysis of sway in Parkinson's disease using a new inclinometry-based method

In order to analyze balance control, we developed a new inclinometry-based method to provide direct information about body sway in the side-to-side and forward-backward directions. We tested the clinical utility of this method for analyzing balance in Parkinson's disease (PD), and studied the clinical correlates of the balance measures in PD. Postural sway was measured during quiet stance with eyes open and eyes closed in 28 PD patients and in 32 age- and sex-matched control subjects. Postural sway was modeled using side-to-side and forward-backward directional sway movements, sway velocity, and sway area. The amount of postural sway in the PD patients was greater than in the control subjects, the higher level being most marked in patients with severe or long-duration PD. All the side-to-side directional sway parameters were abnormal in the PD patients compared with the control subjects (P < 0.05), whereas the forward-backward directional parameters did not differentiate the two groups. The most sensitive measures of sway were path length, velocity, and area. The duration and severity of PD seem to be particularly associated with the amount of side-to-side directional postural sway. This new inclinometric method appears to be useful in quantifying postural sway and evaluating balance impairment in PD.

Trunk movement in Parkinson's disease during rising from seated position

Parkinson's disease (PD) is associated with particular difficulties rising from a seated position. Little is known about the mechanisms of sit-to-stand in this condition. We sought to define trunk movement during sit-to-stand in a group of patients with PD. Six patients and seven normal volunteers were studied using a six camera ELITE motion analysis system (BTS, Milan, Italy), which permitted data collection in the coronal, sagittal, and transverse planes. Retroreflective markers were positioned along the spine at C7, T3, T6, T9, T12, L3, and the sacrum. Whole-trunk kinematics and the movement at the six different trunk markers were recorded during rising. PD patients have a significantly greater degree of trunk flexion than controls, showing a significant increase in angular velocity of the trunk in the sagittal plane. The total range of movement of trunk rotation was significantly smaller in the PD group, but lateral movement in the trunk was greater than normal. These data suggest that patients with early PD compensate for their difficulties rising from a chair by generating greater trunk flexion at higher angular velocity, thus developing greater forward momentum. This process results in a decrease in the duration of the unstable transitional phase of sit-to-stand, allowing PD patients to reach the upright position as easily and safely as possible. Small rotational movements are an effective way to maintain the centre of mass within the base of support during sit-to-stand. This mechanism appears to be denied to the PD patients who may use increased movements in the coronal plane as an alternative strategy.

Dynamic posturography using a new movable multidirectional platform driven by gravity

Human upright balance control can be quantified using movable platforms driven by servo-controlled torque motors (dynamic posturography). We introduce a new movable platform driven by the force of gravity acting upon the platform and the subject standing on it. The platform consists of a 1 m2 metal plate, supported at each of its four corners by a cable and two magnets. Sudden release of the magnets on three sides of the platform (leaving one side attached) induces rotational perturbations in either the pitch or roll plane. Release of all magnets causes a purely vertical displacement. By varying the slack in the supporting cables, the platform can generate small (0.5 degrees ) to very destabilising (19 degrees ) rotations. Experiments in healthy subjects showed that the platform generated standardised and reproducible perturbations. The peak rotation velocity well exceeded the threshold required to elicit postural responses in the leg muscles. Onset latencies were comparable to those evoked by torque motor-driven platforms. Randomly mixed multidirectional perturbations of large amplitude forced the subject to use compensatory steps (easily possible on the large support surface), with little confounding influence of habituation. We conclude that this gravity-driven multidirectional platform provides a useful and versatile tool for dynamic posturography.

Parkinson's disease impairs the ability to change set quickly

We tested the hypothesis that basal ganglia dysfunction in Parkinson's disease impairs the ability to quickly change set. The ability to change set was inferred by measuring the change in the amplitude of automatic gastrocnemius or tibialis anterior muscle responses in standing subjects: (1) when the direction of a surface perturbation changed from a backward translation to a toes up rotation; and (2) when subjects were instructed to 'give' or 'resist' while responding to the translations and rotations. In experiment 1, a change in sensorimotor set was assessed by the suppression of gastrocnemius responses to toes up rotations following a series of backward translations. Unlike healthy young and older subjects, Parkinson subjects did not change sensorimotor set immediately to the first rotation, but needed several rotations to change their responses. When required to alternate their responses between backward translations and toes up rotations, Parkinson subjects showed a smaller amplitude change in gastrocnemius responses. In experiment 2, Parkinson subjects had more difficulty in using cognitive set to modify their responses, especially when instructed to 'resist' the perturbations. A small number of healthy older subjects also had difficulties changing set quickly, but to a lesser extent than the Parkinson subjects. Levodopa medication did not improve the Parkinson subjects' ability to change set quickly. These results suggest that the basal ganglia, which are affected in Parkinson's disease, are critical neural substrates in the ability to change set quickly.

Assessing muscle stiffness from quiet stance in Parkinson's disease

In previous studies, we developed a postural stiffness measure that is extracted from foot center-of-pressure (COP) trajectories from quietly standing individuals and is based on an analytical mechanical model of posture control. Here we apply this measure to patients with Parkinson's disease (PD). We correlated the postural stiffness measure with different clinical rating scales, obtained from patients. Kendall's rank correlation was highly significant between the stiffness measure and rigidity, bradykinesia, posture impairment, gait, and leg agility, respectively, as rated by the Unified Parkinson's Disease Rating Scale. These results provide further evidence that a higher intrinsic muscle stiffness may contribute to the aforementioned clinically defined symptoms. From a clinical standpoint, this work indicates that the proposed postural stiffness measure may be useful as an assessment tool for the evaluation of PD patients subsequent to pharmacological and surgical treatment.

Habituation of lower leg stretch responses in Parkinson's disease

In young healthy subjects, initially large stretch responses in leg muscles are progressively attenuated following a series of identical postural perturbations. We have studied whether this habituation of stretch responses is impaired in Parkinson's disease. Ten patients and 10 elderly controls received 10 serial 'toe-up' rotational perturbations (amplitude 10 degrees) while standing on a supporting forceplate. We recorded posturally destabilizing medium latency (ML) stretch responses from the medial gastrocnemius muscle. Functional habituation across the first few trials occurred in patients, but not in elderly controls. The rate of habituation was influenced by the size of the response to the first perturbation. This observation explained the absence of habituation in elderly subjects because their responses during the first few trials were much smaller compared to patients. These results suggest that habituation of lower leg stretch responses is unimpaired in Parkinson's disease. The presence of initially large and 'unpracticed' responses may partially explain why Parkinson patients fall in response to unexpected postural disturbances that commonly occur in daily life.

Prolonged duration of standing up is an early dopa-sensitive abnormality in Parkinson's disease

We studied the influence of dopaminergic medication on the duration of standing up, static posture and gait in five patients with Parkinson's disease (Hoehn and Yahr stage 1.5 to 3) and four healthy controls, using an optoelectronic camera system. Duration of standing up was prolonged in patients, while static posture and gait were largely unaffected. The prolonged duration of standing up was corrected by dopaminergic medication. These results suggest that an increased duration of standing up is a relatively early and dopa-sensitive abnormality in Parkinson's disease.

Influence of dopaminergic medication on automatic postural responses and balance impairment in Parkinson's disease

It is still unclear why balance impairment in Parkinson's disease (PD) often responds insufficiently to dopaminergic medication. We have studied this issue in 23 patients with idiopathic PD and 24 healthy controls. Our specific purposes were (a) to investigate the contribution of abnormal automatic postural responses to balance impairment in PD and (b) to assess the influence of dopaminergic medication on abnormal automatic postural responses and balance impairment. Standing subjects received 4 degrees "toe-up" rotational perturbations of a supporting forceplate. We bilaterally recorded posturally destabilizing medium latency (ML) responses from the stretched gastrocnemius muscles and functionally corrective long latency (LL) responses from the shortened tibialis anterior (TA) muscles. We also assessed changes in the center of foot pressure (CFP) and the center of gravity (COG). All patients were tested in the "off" and "on" phases. All controls were tested and retested after 1 h. During the off phase, we found enlarged ML amplitudes and diminished LL amplitudes in patients, together with a markedly increased posterior displacement of the COG. The abnormal ML and LL responses were partially responsible for the increased body sway in patients because the initial forward (destabilizing) displacement of the CFP was increased, while the subsequent backward displacement of the CFP (a measure of the corrective braking action of LL responses) was delayed. Abnormal late automatic or possibly more voluntary postural corrections also contributed substantially to the increased body sway. During the on phase, ML amplitudes were reduced in patients but remained increased compared with controls. LL amplitudes no longer differed between both groups due to a modest, possibly dopamine-related increase in patients and a simultaneous decrease in controls. The abnormal CFP displacement was only partially improved by dopaminergic medication. The later postural corrections were not improved at all. Consequently, the increased posterior COG displacement was not ameliorated during the on phase. We conclude that (a) a combination of abnormal automatic and perhaps more voluntary postural corrections contributes to increased body sway in PD and (b) dopaminergic medication fails to improve balance impairment in PD because early automatic postural responses are only partially corrected, while later occurring postural corrections are not improved at all. These electrophysiological results support clinical observations and suggest that nondopaminergic lesions play a significant role in the pathophysiology of postural abnormalities in PD.

Long latency postural reflexes are under supraspinal dopaminergic control

Scaling of posturally stabilizing long latency (LL) reflexes in tibialis anterior muscles induced by "toe-up" rotational perturbations is abnormal in standing patients with Parkinson's disease. To investigate the contribution of dopaminergic pathways to abnormal scaling, we studied LL reflexes in 22 patients with selective hypodopaminergic syndromes: 10 psychiatric patients taking chronic neuroleptic medication (7 with mild parkinsonism), 8 patients with young-onset Parkinson's disease, and 4 patients with MPTP-induced parkinsonism. Results were compared with those of 10 healthy controls. Stimuli consisted of (a) 10 serial (predictable) perturbations of 4 degrees amplitude, (b) 10 serial (predictable) perturbations of 10 degrees amplitude, and (c) 20 randomly mixed (unpredictable) perturbations of either 4 or 10 degrees amplitude. In normal subjects, LL reflex amplitudes were adapted to match predictable variations in stimulus size, whereas under unpredictable conditions a "default" response emerged that anticipated the 10 degrees perturbation. LL reflex scaling under predictable conditions was intact in patients with neuroleptic-induced parkinsonism and young-onset Parkinson's disease, but the large default LL response under unpredictable conditions was absent. In patients with MPTP-induced parkinsonism, LL reflex scaling was absent during both predictable and unpredictable conditions. We conclude that abnormal scaling of posturally stabilizing LL reflexes is related to decreased supraspinal dopaminergic influence.