Dissociation of 'on-line' and 'off-line' visuomotor control of the arm by focal lesions in the cerebellum and brainstem

The cerebellum monitors errors and entrains executive networks

Frontal midline θ (Fmθ) activity occurs in medial prefrontal cortices (mPFC), when expected and actual outcomes conflict. Cerebellar forward models could inform the mPFC about this mismatch. To verify this hypothesis we correlated the mPFC activation during a visuomotor tracking task (VM) with performance accuracy, in control and cerebellum-lesioned participants. Additionally, purely visual (V), motor (M) and a motor plus visual tasks (V + M) were performed. An Independent Component, with a mid-frontal topography scalp map and equivalent dipole location in the dorsal anterior cingulate cortex accounted for Fmθ. In control participants Fmθ power increased during VM, when the error level crossed a threshold, but not during V + M, M and V. This increase scaled with tracking error. Fmθ power failed to increase during VM in cerebellar participants, even at highest tracking errors. Thus, in control participants, activation of mPFC is induced when a continuous monitoring effort for online error detection is required. The presence of a threshold error for enhancing Fmθ, suggests the switch from an automatic to an executive tracking control, which recruits the mPFC. Given that the cerebellum stores forward models, the absence of Fmθ increases during tracking errors in cerebellar participants indicates that cerebellum is necessary for supplying the mPFC with prediction error-related information. This occurs when automatic control falters, and a deliberate correction mechanism needs to be triggered. Further studies are needed to verify if this alerting function also occurs in the context of the other cognitive and non-cognitive functions in which the cerebellum is involved.

Cerebellar Dysfunction in Multiple Sclerosis: Considerations for Research and Rehabilitation Therapy

Introduction. Cerebellar pathology is common among persons with multiple sclerosis (PwMS). The cerebellum is well recognized for its role in motor control and motor learning and cerebellar pathology in multiple sclerosis is associated with enhanced motor impairment and disability progression. The Problem. To mitigate motor disability progression, PwMS are commonly prescribed exercise and task-specific rehabilitation training. Yet, whether cerebellar dysfunction differentially affects rehabilitation outcomes in this population remains unknown. Furthermore, we lack rehabilitation interventions targeting cerebellar dysfunction. The Solution. Here, we summarize the current understanding of the impact of cerebellar dysfunction on motor control, motor training, and rehabilitation in persons with multiple sclerosis. Recommendations. Additionally, we highlight critical knowledge gaps and propose that these guide future research studying cerebellar dysfunction in persons with multiple sclerosis.

Effect of dual tasking on a dynamic balance task in children with and without DCD

The purpose of this study was to compare performance of children with Developmental Coordination Disorder (DCD) and typically developing (TD) children in a dual task paradigm with a dynamic balance task on the Wii Fit as primary task and a concurrent cognitive (counting) or a concurrent bimanual fine motor task as secondary tasks. Using a cross-sectional design, 25 children with DCD and 38 TD children were assessed with the Movement Assessment Battery for Children, 2nd edition (MABC-2) and Divided Attention (DA) task of the KiTAP. Next, the single- and dual-tasks were performed and the level of interference or facilitation of the dual tasks was calculated. Regression analysis determined the predictive value of the DA and MABC-2 component balance outcomes on the dual task performance. On the motor and attentional tasks, the group of children with DCD scored significantly below the level of the TD children. The dual task effect showed similar interference and facilitation of tasks in the different dual-task conditions in both groups. In the dual task-cognitive condition, the divided attention abilities and the MABC-2 balance score predicted 25% of the Wii Fit dynamic balance task performance, whereas in the dual task-motor condition this was higher (31.6%). In both conditions, DA was a stronger predictor than MABC balance score and appears to be an important factor to consider when developing motor task training for children with DCD.

Human electrocortical dynamics while stepping over obstacles

To better understand human brain dynamics during visually guided locomotion, we developed a method of removing motion artifacts from mobile electroencephalography (EEG) and studied human subjects walking and running over obstacles on a treadmill. We constructed a novel dual-layer EEG electrode system to isolate electrocortical signals, and then validated the system using an electrical head phantom and robotic motion platform. We collected data from young healthy subjects walking and running on a treadmill while they encountered unexpected obstacles to step over. Supplementary motor area and premotor cortex had spectral power increases within ~200 ms after object appearance in delta, theta, and alpha frequency bands (3–13 Hz). That activity was followed by similar posterior parietal cortex spectral power increase that decreased in lag time with increasing locomotion speed. The sequence of activation suggests that supplementary motor area and premotor cortex interrupted the gait cycle, while posterior parietal cortex tracked obstacle location for planning foot placement nearly two steps ahead of reaching the obstacle. Together, these results highlight advantages of adopting dual-layer mobile EEG, which should greatly facilitate the study of human brain dynamics in physically active real-world settings and tasks.

Effect of visual information on step-tracking movements in patients with intention tremor due to multiple sclerosis

The effect of visual information on step-tracking movements was studied in 18 patients with intention tremor due to multiple sclerosis (MS) and 15 healthy controls. Participants performed a slow wrist step-tracking task with stationary targets under five visual feedback conditions. The display of the target and movement cues was selectively withdrawn to examine the effects of visual information on intention tremor and movement accuracy.

Results showed that intentio n tremor was most pronounced when visual display of both target and movement cues was available. Withdrawing visual information of the limb movement reduced tremor more than withdrawing the visual display of the target cues. Both the patient and control group was less accurate when the display of limb movement was occluded. Patients, however, were more dependent on visual information of the limb movement for accurate motor performance than healthy controls.

When the visual display of the limb movement was partially occluded between or near to the targets, tremor decreased without deterioration of movement accuracy.

Automatic online control of motor adjustments in reaching and grasping

Following the princeps investigations of Marc Jeannerod on action-perception, specifically, goal-directed movement, this review article addresses visual and non-visual processes involved in guiding the hand in reaching or grasping tasks. The contributions of different sources of correction of ongoing movements are considered; these include visual feedback of the hand, as well as the often-neglected but important spatial updating and sharpening of goal localization following gaze-saccade orientation. The existence of an automatic online process guiding limb trajectory toward its goal is highlighted by a series of princeps experiments of goal-directed pointing movements. We then review psychophysical, electrophysiological, neuroimaging and clinical studies that have explored the properties of these automatic corrective mechanisms and their neural bases, and established their generality. Finally, the functional significance of automatic corrective mechanisms-referred to as motor flexibility-and their potential use in rehabilitation are discussed.

Understanding tremor in multiple sclerosis: prevalence, pathological anatomy, and pharmacological and surgical approaches to treatment

Background

Given that tremor is one of the most prevalent and disabling features of multiple sclerosis (MS), we will review the most significant milestones in tremor in this disease in recent years, focusing on prevalence, clinical features, anatomical basis, and treatment.

Methods

Data for this review were identified by searching MEDLINE with the search terms “multiple sclerosis” and “tremor”. References were also identified from relevant articles published between January 1966 and May 2012.

Results

The predominant type of MS tremor is a large-amplitude, postural, and kinetic tremor, which most commonly affects the arms, although tremor can also involve head, neck, vocal cords, and trunk. Involvement of the tongue, jaw, or palate has not been reported. Although the anatomical basis underlying tremor in MS is poorly understood, the link between the cerebellum and the MS-related tremor is supported by clinical and experimental studies. Currently available medication is often unsuccessful in most cases. Surgical treatment can be a satisfactory alternative to treat severe and disabling tremor.

Discussion

Tremor in MS patients could be considered as an advanced consequence of the disease and its presence suggests a more aggressive course. MS tremor can be severe and very disabling for a small group of patients. Treatment of MS tremor remains a great challenge. Recent studies suggest that dissociating tremor from cerebellar dysfunction using selected clinical tests would be the key issue to successful surgical treatment. Understanding the pathophysiology and biochemistry of tremor production in MS may lead to new therapeutic approaches.

Consensus paper: roles of the cerebellum in motor control--the diversity of ideas on cerebellar involvement in movement

Considerable progress has been made in developing models of cerebellar function in sensorimotor control, as well as in identifying key problems that are the focus of current investigation. In this consensus paper, we discuss the literature on the role of the cerebellar circuitry in motor control, bringing together a range of different viewpoints. The following topics are covered: oculomotor control, classical conditioning (evidence in animals and in humans), cerebellar control of motor speech, control of grip forces, control of voluntary limb movements, timing, sensorimotor synchronization, control of corticomotor excitability, control of movement-related sensory data acquisition, cerebro-cerebellar interaction in visuokinesthetic perception of hand movement, functional neuroimaging studies, and magnetoencephalographic mapping of cortico-cerebellar dynamics. While the field has yet to reach a consensus on the precise role played by the cerebellum in movement control, the literature has witnessed the emergence of broad proposals that address cerebellar function at multiple levels of analysis. This paper highlights the diversity of current opinion, providing a framework for debate and discussion on the role of this quintessential vertebrate structure.

Behavioural significance of cerebellar modules

A key organisational feature of the cerebellum is its division into a series of cerebellar modules. Each module is defined by its climbing input originating from a well-defined region of the inferior olive, which targets one or more longitudinal zones of Purkinje cells within the cerebellar cortex. In turn, Purkinje cells within each zone project to specific regions of the cerebellar and vestibular nuclei. While much is known about the neuronal wiring of individual cerebellar modules, their behavioural significance remains poorly understood. Here, we briefly review some recent data on the functional role of three different cerebellar modules: the vermal A module, the paravermal C2 module and the lateral D2 module. The available evidence suggests that these modules have some differences in function: the A module is concerned with balance and the postural base for voluntary movements, the C2 module is concerned more with limb control and the D2 module is involved in predicting target motion in visually guided movements. However, these are not likely to be the only functions of these modules and the A and C2 modules are also both concerned with eye and head movements, suggesting that individual cerebellar modules do not necessarily have distinct functions in motor control.

The effect of levetiracetam on tremor severity and functionality in patients with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) intention tremor is a disabling symptom, which is difficult to treat.

OBJECTIVES

To investigate the effects of levetiracetam, an antiepileptic drug, on tremor severity and related functionality in MS.

METHODS

A randomized, double-blind, placebo-controlled, cross-over study examined the effects of 6 weeks of oral levetiracetam administration (starting dose=250 mg/day, maximal dose=2000 mg/day) in 18 MS patients with disabling intention tremor. Primary outcome was Fahn's Tremor Rating Scale (FTRS) A&B. Secondary outcome measures were the nine-hole peg test, patient's opinion rated with the visual analog scale, FTRS C, and an activities of daily life questionnaire and validated tremor indexes derived during the performance of a digitized spiral drawing task and a wrist step-tracking task. Repeated measures analysis of variance and Friedman tests were applied.

RESULTS

In all, 14 patients completed the trial. Maximal dose intake ranged from 1000 to most commonly 2000 mg, depending on patients' tolerance level. No significant effects of levetiracetam were found for any outcome measure. Further analyses on subgroups with different tremor severity showed no differential effects. Eight patients reported adverse events such as fatigue and stomach ache.

CONCLUSIONS

Levetiracetam intake of 2000 mg/day did not affect tremor severity or functionality in patients with MS.

Visuokinesthetic perception of hand movement is mediated by cerebro-cerebellar interaction between the left cerebellum and right parietal cortex

Combination of visual and kinesthetic information is essential to perceive bodily movements. We conducted behavioral and functional magnetic resonance imaging experiments to investigate the neuronal correlates of visuokinesthetic combination in perception of hand movement. Participants experienced illusory flexion movement of their hand elicited by tendon vibration while they viewed video-recorded flexion (congruent: CONG) or extension (incongruent: INCONG) motions of their hand. The amount of illusory experience was graded by the visual velocities only when visual information regarding hand motion was concordant with kinesthetic information (CONG). The left posterolateral cerebellum was specifically recruited under the CONG, and this left cerebellar activation was consistent for both left and right hands. The left cerebellar activity reflected the participants' intensity of illusory hand movement under the CONG, and we further showed that coupling of activity between the left cerebellum and the "right" parietal cortex emerges during this visuokinesthetic combination/perception. The "left" cerebellum, working with the anatomically connected high-order bodily region of the "right" parietal cortex, participates in online combination of exteroceptive (vision) and interoceptive (kinesthesia) information to perceive hand movement. The cerebro-cerebellar interaction may underlie updating of one's "body image," when perceiving bodily movement from visual and kinesthetic information.

Kinematic analysis of thalamic versus subthalamic neurostimulation in postural and intention tremor

Deep brain stimulation of the thalamus (thalamic DBS) is an established therapy for medically intractable essential tremor and tremor caused by multiple sclerosis. In both disorders, motor disability results from complex interaction between kinetic tremor and accompanying ataxia with voluntary movements. In clinical studies, the efficacy of thalamic DBS has been thoroughly assessed. However, the optimal anatomical target structure for neurostimulation is still debated and has never been analysed in conjunction with objective measurements of the different aspects of motor impairment. In 10 essential tremor and 11 multiple sclerosis patients, we analysed the effect of thalamic DBS through each contact of the quadripolar electrode on the contralateral tremor rating scale, accelerometry and kinematic measures of reach-to-grasp-movements. These measures were correlated with the anatomical position of the stimulating electrode in stereotactic space and in relation to nuclear boundaries derived from intraoperative microrecording. We found a significant impact of the stereotactic z-coordinate of stimulation contacts on the TRS, accelerometry total power and spatial deviation in the deceleration and target period of reach-to-grasp-movements. Most effective contacts clustered within the subthalamic area (STA) covering the posterior Zona incerta and prelemniscal radiation. Stimulation within this region led to a mean reduction of the lateralized tremor rating scale by 15.8 points which was significantly superior to stimulation within the thalamus (P < 0.05, student's t-test). STA stimulation resulted in reduction of the accelerometry total power by 99%, whereas stimulation at the ventral thalamic border (68%) or within the thalamus proper (2.5%) was significantly less effective (P < 0.01). Concomitantly, STA stimulation led to a significantly higher increase of tremor frequency and decrease in EMG synchronization compared to stimulation within the thalamus proper (P < 0.001). In reach-to-grasp movements, STA stimulation reduced the spatial variability of the movement path in the deceleration period by 28.9% and in the target period by 58.4%, whereas stimulation within the thalamus was again significantly less effective (P < 0.05), with a reduction in the deceleration period between 6.5 and 21.8% and in the target period between 1.2 and 11.3%. An analysis of the nuclear boundaries from intraoperative microrecording confirmed the anatomical impression that most effective electrodes were located within the STA. Our data demonstrate a profound effect of deep brain stimulation of the thalamic region on tremor and ataxia in essential tremor and tremor caused by multiple sclerosis. The better efficacy of stimulation within the STA compared to thalamus proper favours the concept of a modulation of cerebello-thalamic projections underlying the improvement of these symptoms.

Online movement control in multiple sclerosis patients with tremor: effects of tendon vibration

Patients with intention tremor due to multiple sclerosis (MS) exhibit an increased reliance on visual feedback in the sensorimotor control of slow goal-directed movements. In the present study, the use of proprioceptive information was investigated in MS patients with intention tremor compared to MS patients without tremor and healthy controls. Tendon vibration was applied to the wrist extensor muscles during a memory-guided slow wrist step-tracking task to investigate the use of muscle spindle afferent information in online movement control. A significant reduction of movement amplitude was induced by tendon vibration in all three groups, but the effect was found to be smaller in MS patients with tremor (28%) than in subjects without tremor (50%). Vibration also induced an increase of overall tremor amplitude in the MS tremor group; however, its effect on movement amplitude was not directly related to (changes in) tremor severity. The results suggest that the decreased online use of proprioceptive information in MS patients with tremor reflects an adaptation over time to cope with a tremor-related noisy background. Abnormalities in proprioceptive processing may explain why MS patients with tremor show an increased reliance on visual feedback for online motor control.

Eye movements coordinated with steering benefit performance even when vision is denied

When driving along a winding road, eye movements and steering are tightly linked. When approaching a bend, the driver looks across to the inside kerb (the tangent point) some time before turning the steering wheel. All drivers we have tested show this optimal coordination, without which driving is impaired. An intriguing question is how much of the benefit for steering arises just from moving the eyes in this coordinated way (ahead of steering and in the same direction), and how much from the visual information that the eyes move to acquire, in this instance the foveated tangent point. This can be answered by dissociating the two, by reducing visibility of the road ahead (and crucially of the tangent point) to a level at which drivers might or might not choose to move their eyes but, if they do, will not gain the information they seek. Twenty subjects repeatedly drove a simulated stage of the World Rally Championship. With full visibility, they exhibited the usual coordination of eye movements and steering. Subsequently, visibility was reduced on the left hand side. Drivers who persisted in making eye movements coordinated with steering to the left, despite the fact that they could no longer see the tangent point on that side, performed better than drivers who under the identical conditions did not look to the left. This confirms that the making of coordinated eye movements itself benefits steering, even when the eye movements do not yield the visual information sought.

Neurophysiologic intervention in deep brain stimulation treatment for movement disorders: a practical framework

Clinical neurophysiology has always played an important interventional role throughout the perioperative stages in functional neurosurgery. On the one hand, some neurophysiologic procedures have become an integrated part of neurosurgery. On the other hand, in deep brain stimulation, although the surgical electrode implantation is an essential step, the therapeutic effects are actually produced by electrically modulating the physiologic activity of the brain. We review the topic of neurophysiologic intervention in the deep brain stimulation for movement disorders by presenting the evidence derived from our own experiences based on an integrated group located at two hospitals in London and Oxford, UK, and mainly covering tremor caused by multiple sclerosis, Parkinson's disease and dystonia.

The effect of changed visual feedback on intention tremor in multiple sclerosis

In patients with multiple sclerosis (MS), intention tremor amplitude is enhanced during the visually guided compared to the memory guided motor tasks. In the present study, the effect of visual feedback on intention tremor was investigated during visually guided wrist step-tracking tasks. Specifically, visual feedback of the hand was provided either instantly or averaged over different time windows. Thirteen MS patients with intention tremor and 14 healthy controls performed the wrist step-tracking task, while the visual representation of the actual hand position was displayed instantly or averaged over time windows of 150, 250 and 350 ms. It has been found in the patient group that, in association with a decreased initial error and decreased tremor amplitude on the screen, the amplitude of the actual performed tremor also decreased when visual feedback was changed. The tremor reduction was not different between conditions with manipulated feedback, although delays in presenting visual feedback of the hand position increased when the time window was larger. The reduction in overall tremor amplitude was unlikely related to other factors, such as eye fixation deficits or the speed of the primary hand movement. These results suggest that hand tremor severity is dependent on the visual feedback of position and movement errors.

Purkinje cells in the lateral cerebellum of the cat encode visual events and target motion during visually guided reaching

In this study the receipt of visual information by the lateral cerebellum and its contribution to a motor output was studied using single unit recording of cerebellar cortical neurones in cats trained to perform visually guided reaching. The activity of Purkinje cells and other cortical neurones in the lateral cerebellum was investigated in relation to various aspects of the task, such as visual events, parameters of target movement, and limb and eye movements. Two-thirds (66%) of Purkinje cells tested could signal simple visual events, such as a flash of light. Neurones were also capable of detecting other less potent, but behaviourally important visual events, such as a 'GO' signal (LED brightening). Half of the cells tested were responsive to the on-going motion of the visual target, displaying tonically altered discharge rates for as long as it was moving, and a 'preferred' target velocity. A small proportion of cells showed short latency visual modulation that persisted during the forelimb reach. Anatomical tracing studies confirmed that the recordings were obtained from the D1 zone of crus I. In summary, cells in this region of lateral cerebellar cortex perform simple visual functions, such as event detection, but also more complex visual functions, such as encoding parameters of target motion, and their visual responsiveness is appropriate for a role in accurate visually guided reaching to a moving target.

Relationship between multiple sclerosis intention tremor severity and lesion load in the brainstem

Intention tremor due to multiple sclerosis is clinically similar to cerebellar tremor. This study investigated, in 14 multiple sclerosis patients, the relationship between intention tremor severity and the lesion load in different infratentorial regions. Tremor amplitude was quantified during step-tracking tasks. The lesion load was measured on magnetic resonance images using an automated segmentation method. Intention tremor amplitude was significantly related to lesion load in the brainstem but not in the cerebellum. Specifically, tremor amplitude correlated with the lesion load in the contralateral pons, and patients with more severe tremor in both arms had a greater lesion load bilaterally in the pons. These results support the view that multiple sclerosis intention tremor is related to dysfunction of cerebellar inflow and/or outflow pathways.

Intention tremor during manual aiming: a study of eye and hand movements

Accurate goal-directed movements toward a visual target require a precise coordination of both the oculomotor and limb motor systems. Intention tremor and eye movement deficits are frequently observed in multiple sclerosis (MS). The goal of this study was to examine the characteristics of intention tremor and simultaneously produced eye movements during rapid goal-directed movements. Eye and hand movements were synchronously measured in 16 MS patients with intention tremor and 16 control subjects. Manual performances of the patient group were characterized by a delayed onset, slower execution and aiming inaccuracies. In line with the clinically defined picture of intention tremor differences between patients and control subjects were most pronounced toward the end of the movement. Dependent variables were obviously greater in MS patients compared with control subjects, and correlated well with clinical outcome measures. The application of an inertial load to the limb did not show any effect on intention tremor. In addition to impaired limb coordination, evidence has been found that eye movements, too, were abnormal in patients compared with control subjects. Moreover, eye and hand movement deficits seemed to be closely related, suggesting a common underlying command structure. Inaccurate eye movements were likely to hamper an accurate motor performance of the hand.

The cerebellum and the timing of coordinated eye and hand tracking

The cerebellum is known to have important functions in motor control, coordination, motor learning, and timing. It may have other "higher" functions as well, up to and including cognitive processing independent of motor behavior. In this article, we will review some of the evidence from functional imaging, lesion studies, electrophysiological recordings, and anatomy which support the theory that the cerebellum provides a "forward model" of the motor system. This forward model would be used for control of movement; it could also underlie a cerebellar role in coordination. In this role, the forward model would generate time-specific signals predicting the motion of each motor effector, essential for predictive control of, for example, eye and hand movements. Data are presented from human eye and hand tracking that support this. Tracking performance is better if eye and hand follow the same spatial trajectory, but better still if the eye leads the hand by about 75 to 100 ms. This suggests that information from the ocular control system feeds into the manual control system to assist its tracking.

Development of externally guided grip force modulation in man

We examined the development of externally guided changes of grip force with respect to force rate and direction of force change. Sixty-nine children, 3-6 years of age, and 17 adults produced increasing or decreasing isometric forces on a small cylindrical sensor using a pinch grip with visual feedback. Force changes were instructed with a visual tracking task. Ramp-like paradigms with both force increase and force decrease and two different target force rates were used (0.5 N/s, 1.25 N/s). Precision of force tracking showed clear age effects and was influenced by the required force rates and directions of force change. In adults, tracking errors were much more dependent on target force rate and direction than in children. Up to four years of age, the children tended to overshoot the target force change in a 'jump and wait' manner in all conditions except for fast target force decreases. Older children tended to overshoot only in the condition with slow target force decrease. Adults showed close undershooting in all conditions when following the target. Adults used either a continuous 'following' strategy or a 'see and catch-up' strategy. The distinct effects on tracking errors suggest an age-related change of strategies from a feedforward strategy with intermittent use of sensorimotor feedback towards a fairly parallel and well-integrated feedback and feedforward processing. A critical age appears to be around five to six years. We suggest that these age effects may reflect distinct developmental velocities of neuronal subpopulations of the cortex and of the cerebello-cortical connections.