High motor variability in DYT1 dystonia is associated with impaired visuomotor adaptation

A Serious Game for the Assessment of Visuomotor Adaptation Capabilities during Locomotion Tasks Employing an Embodied Avatar in Virtual Reality

The study of visuomotor adaptation (VMA) capabilities has been encompassed in various experimental protocols aimed at investigating human motor control strategies and/or cognitive functions. VMA-oriented frameworks can have clinical applications, primarily in the investigation and assessment of neuromotor impairments caused by conditions such as Parkinson's disease or post-stroke, which affect the lives of tens of thousands of people worldwide. Therefore, they can enhance the understanding of the specific mechanisms of such neuromotor disorders, thus being a potential biomarker for recovery, with the aim of being integrated with conventional rehabilitative programs. Virtual Reality (VR) can be entailed in a framework targeting VMA since it allows the development of visual perturbations in a more customizable and realistic way. Moreover, as has been demonstrated in previous works, a serious game (SG) can further increase engagement thanks to the use of full-body embodied avatars. Most studies implementing VMA frameworks have focused on upper limb tasks and have utilized a cursor as visual feedback for the user. Hence, there is a paucity in the literature about VMA-oriented frameworks targeting locomotion tasks. In this article, the authors present the design, development, and testing of an SG-based framework that addresses VMA in a locomotion activity by controlling a full-body moving avatar in a custom VR environment. This workflow includes a set of metrics to quantitatively assess the participants' performance. Thirteen healthy children were recruited to evaluate the framework. Several quantitative comparisons and analyses were run to validate the different types of introduced visuomotor perturbations and to evaluate the ability of the proposed metrics to describe the difficulty caused by such perturbations. During the experimental sessions, it emerged that the system is safe, easy to use, and practical in a clinical setting. Despite the limited sample size, which represents the main limitation of the study and can be compensated for with future recruitment, the authors claim the potential of this framework as a useful instrument for quantitatively assessing either motor or cognitive impairments. The proposed feature-based approach gives several objective parameters as additional biomarkers that can integrate the conventional clinical scores. Future studies might investigate the relation between the proposed biomarkers and the clinical scores for specific disorders such as Parkinson's disease and cerebral palsy.

Harnessing cognitive strategy use for functional problems and proposed underlying mechanisms in childhood-onset dystonia

BACKGROUND

There is a significant gap in knowledge about rehabilitation techniques and strategies that can help children and young people with hyperkinetic movement disorders (HMD) including dystonia to successfully perform daily activities and improve overall participation. A promising approach to support skill acquisition is the Cognitive Orientation to daily Occupational Performance (CO-OP) intervention. CO-OP uses cognitive strategies to help patients generate their own solutions to overcome self-identified problems encountered in everyday living.

PURPOSE

1. To identify and categorize strategies used by children with HMD to support skill acquisition during CO-OP; 2. To review the possible underlying mechanisms that might contribute to the cognitive strategies, in order to facilitate further studies for developing focused rehabilitation approaches.

METHODS

A secondary analysis was performed on video-recorded data from a previous study exploring the efficacy of CO-OP for childhood onset HMD, in which CO-OP therapy sessions were delivered by a single occupational therapist. For the purpose of this study, we reviewed a total of 40 randomly selected hours of video footage of CO-OP sessions delivered to six participants (age 6-19 years) over ten intervention sessions. An observational recording sheet was applied to identify systematically the participants' or therapist's verbalizations of cognitive strategies during the therapy. The strategies were classified into six categories in line with published literature.

RESULTS

Strategies used by HMD participants included distraction, externally focussed attention, internally focussed attention, emotion self-regulation, motor imagery and mental self-guidance. We postulate different underlying working mechanisms for these strategies, which have implications for the therapeutic management of children and young people with HMD including dystonia.

CONCLUSIONS

Cognitive strategy training can fundamentally change and improve motor performance. On-going work will address both the underlying neural mechanisms of therapeutic change and the mediators and moderators that influence how change unfolds.

The dissociable effects of reward on sequential motor behavior

Reward has consistently been shown to enhance motor behavior; however, its beneficial effects appear to be largely unspecific. For example, reward is associated with both rapid and training-dependent improvements in performance, with a mechanistic account of these effects currently lacking. Here we tested the hypothesis that these distinct reward-based improvements are driven by dissociable reward types: monetary incentive and performance feedback. Whereas performance feedback provides information on how well a motor task has been completed (knowledge of performance), monetary incentive increases the motivation to perform optimally without providing a performance-based learning signal. Experiment 1 showed that groups who received monetary incentive rapidly improved movement times (MTs), using a novel sequential reaching task. In contrast, only groups with correct performance-based feedback showed learning-related improvements. Importantly, pairing both maximized MT performance gains and accelerated movement fusion. Fusion describes an optimization process during which neighboring sequential movements blend together to form singular actions. Results from experiment 2 served as a replication and showed that fusion led to enhanced performance speed while also improving movement efficiency through increased smoothness. Finally, experiment 3 showed that these improvements in performance persist for 24 h even without reward availability. This highlights the dissociable impact of monetary incentive and performance feedback, with their combination maximizing performance gains and leading to stable improvements in the speed and efficiency of sequential actions.NEW & NOTEWORTHY Our work provides a mechanistic framework for how reward influences motor behavior. Specifically, we show that rapid improvements in speed and accuracy are driven by reward presented in the form of money, whereas knowledge of performance through performance feedback leads to training-based improvements. Importantly, combining both maximized performance gains and led to improvements in movement quality through fusion, which describes an optimization process during which sequential movements blend into a single action.

A Critical Investigation of Cerebellar Associative Learning in Isolated Dystonia

Background

Objective

Methods

Results

Conclusions

Motor learning deficits in cervical dystonia point to defective basal ganglia circuitry

Dystonia is conceptualized as a network disorder involving basal ganglia, thalamus, sensorimotor cortex and the cerebellum. The cerebellum has been implicated in dystonia pathophysiology, but studies testing cerebellar function in dystonia patients have provided equivocal results. This study aimed to further elucidate motor network deficits in cervical dystonia with special interest in the role of the cerebellum. To this end we investigated motor learning tasks, that differ in their dependence on cerebellar and basal ganglia functioning. In 18 cervical dystonia patients and 18 age matched healthy controls we measured implicit motor sequence learning using a 12-item serial reaction time task mostly targeting basal ganglia circuitry and motor adaptation and eyeblink conditioning as markers of cerebellar functioning. ANOVA showed that motor sequence learning was overall impaired in cervical dystonia (p = 0.01). Moreover, unlike healthy controls, patients did not show a learning effect in the first part of the experiment. Visuomotor adaptation and eyeblink conditioning were normal. In conclusion, these data lend support to the notion that motor learning deficits in cervical dystonia relate to basal ganglia-thalamo-cortical loops rather than being a result of defective cerebellar circuitry.

Interlimb differences in visuomotor and dynamic adaptation during targeted reaching in children

While a number of studies have focused on movement (a)symmetries between the arms in adults, less is known about movement asymmetries in typically developing children. The goal of this study was to examine interlimb differences in children when adapting to novel visuomotor and dynamic conditions while performing a center-out reaching task. We tested 13 right-handed children aged 9-11 years old. Prior to movement, one of eight targets arranged radially around the start position was randomly displayed. Movements were made either with the right (dominant) arm or the left (nondominant) arm. The children participated in two experiments separated by at least one week. In one experiment, subjects were exposed to a rotated visual display (30° about the start circle); and in the other, a 1 kg mass (attached eccentrically to the forearm axis). Each experiment consisted of three blocks: pre-exposure, exposure and post-exposure. Three measures of task performance were calculated from hand trajectory data: hand-path deviation from the straight target line, direction error at peak velocity and final position error. Results showed that during visuomotor adaptation, no interlimb differences were observed for any of the three measures. During dynamic adaptation, however, a significant difference between the arms was observed at the first cycle during dynamic adaptation. With regard to the aftereffects observed during the post-exposure block, direction error data indicate considerably large aftereffects for both arms during visuomotor adaptation; and there was a significant difference between the arms, resulting in substantially larger aftereffects for the right arm. Similarly, dynamic adaptation results also showed a significant difference between the arms; and post hoc analyses indicated that aftereffects were present only for the right arm. Collectively, these findings indicate that the dominant arm advantage for developing an internal model associated with a novel visuomotor or dynamic transform, as previously shown in young adults, may already be apparent at 9 to 11-year old children.

Postural control of arm and fingers through integration of movement commands

Every movement ends in a period of stillness. Current models assume that commands that hold the limb at a target location do not depend on the commands that moved the limb to that location. Here, we report a surprising relationship between movement and posture in primates: on a within-trial basis, the commands that hold the arm and finger at a target location depend on the mathematical integration of the commands that moved the limb to that location. Following damage to the corticospinal tract, both the move and hold period commands become more variable. However, the hold period commands retain their dependence on the integral of the move period commands. Thus, our data suggest that the postural controller possesses a feedforward module that uses move commands to calculate a component of hold commands. This computation may arise within an unknown subcortical system that integrates cortical commands to stabilize limb posture.

Advances in the pathophysiology of adult-onset focal dystonias: recent neurophysiological and neuroimaging evidence

Focal dystonia is a movement disorder characterized by involuntary muscle contractions that determine abnormal postures. The traditional hypothesis that the pathophysiology of focal dystonia entails a single structural dysfunction (i.e. basal ganglia) has recently come under scrutiny. The proposed network disorder model implies that focal dystonias arise from aberrant communication between various brain areas. Based on findings from animal studies, the role of the cerebellum has attracted increased interest in the last few years. Moreover, it has been increasingly reported that focal dystonias also include nonmotor disturbances, including sensory processing abnormalities, which have begun to attract attention. Current evidence from neurophysiological and neuroimaging investigations suggests that cerebellar involvement in the network and mechanisms underlying sensory abnormalities may have a role in determining the clinical heterogeneity of focal dystonias.

Impaired Saccade Adaptation in Tremor-Dominant Cervical Dystonia-Evidence for Maladaptive Cerebellum

We examined the role of the cerebellum in patients with tremor-dominant cervical dystonia by measuring the adaptive capacity of rapid reflexive eye movements (saccades). We chose the saccade adaptation paradigm because, unlike other motor learning paradigms, the real-time modification of saccades cannot "wait" for the sensory (visual) feedback. Instead, saccades rely primarily on the internal reafference modulated by the cerebellum. The saccade adaptation happens over fast and slow timescales. The fast timescale has poor retention of learned response, while the slow timescale has strong retention. Cerebellar defects resulting in loss of function affect the fast timescale but the slow timescale of saccade adaptation is retained. In contrast, maladaptive cerebellar disorders feature the absence of both fast and slow timescales. We were able to measure both timescales using noninvasive oculography in 6 normal individuals. In contrast, both timescales were absent in 12 patients with tremor-dominant cervical dystonia. These findings are consistent with maladaptive cerebellar outflow as a putative pathophysiological basis for tremor-dominant cervical dystonia.

Dysarthria Profiles in Adults With Hereditary Ataxia

Purpose This preliminary study examined whether speech profiles exist for adults with hereditary ataxia based on 2 competing frameworks: a pattern of instability/inflexibility or a pattern of differential subsystem involvement. Method Four dysarthria experts rated the speech samples of 8 adults with dysarthria from hereditary ataxia using visual analog scales and presence/severity rating scales of speech characteristics. Speaking tasks included diadochokinetics, sustained phonation, and a monologue. Results Speech profiles aligned with the instability/inflexibility framework, with the pattern of instability being the most common. Speech profiles did not emerge for the majority of speakers using the differential subsystem framework. Conclusions The findings extend previous research on pure ataxic dysarthria and suggest a possible framework for understanding the speech heterogeneity associated with the ataxias. The predominance of the instability profile is consistent with the notion of impaired feedforward control in speakers with cerebellar disruption.

Sensorimotor Control in Dystonia

This is an overview of the sensorimotor impairments in dystonia, a syndrome characterized by sustained or intermittent aberrant movement patterns leading to abnormal movements and/or postures with or without a tremulous component. Dystonia can affect the entire body or specific body regions and results from a plethora of etiologies, including subtle changes in gray and white matter in several brain regions. Research over the last 25 years addressing topics of sensorimotor control has shown functional sensorimotor impairments related to sensorimotor integration, timing, oculomotor and head control, as well as upper and lower limb control. In the context of efforts to update the classification of dystonia, sensorimotor research is highly relevant for a better understanding of the underlying pathology, and potential mechanisms contributing to global and regional dysfunction within the central nervous system. This overview of relevant research regarding sensorimotor control in humans with idiopathic dystonia attempts to frame the dysfunction with respect to what is known regarding motor control in patients and healthy individuals. We also highlight promising avenues for the future study of neuromotor control that may help to further elucidate dystonia etiology, pathology, and functional characteristics.

The Use of Botulinum Toxin for Treatment of the Dystonias

Dystonias are characterized by involuntary muscle contractions, twisting movements, abnormal postures, and often tremor in various body regions. However, in the last decade several studies have demonstrated that dystonias are also characterized by sensory abnormalities. While botulinum toxin is the gold standard therapy for focal dystonia, exactly how it improves this disorder is not entirely understood. Neurophysiological studies in animals and humans have clearly demonstrated that botulinum toxin improves dystonic motor manifestations by inducing chemodenervation, therefore weakening the injected muscles. In addition, neurophysiological and neuroimaging evidence also suggests that botulinum toxin modulates the activity of various neural structures in the CNS distant from the injected site, particularly cortical motor and sensory areas. Concordantly, recent studies have shown that in patients with focal dystonias botulinum toxin ameliorates sensory disturbances, including reduced spatial discrimination acuity and pain. Overall, these observations suggest that in these patients botulinum toxin-induced effects encompass complex mechanisms beyond chemodenervation of the injected muscles.

Methods for measuring swallowing pressure variability using high-resolution manometry

Any movement performed repeatedly will be executed with inter-trial variability. Oropharyngeal swallowing is a complex sensorimotor action, and swallow-to-swallow variability can have consequences that impact swallowing safety. Our aim was to determine an appropriate method to measure swallowing pressure waveform variability. An ideal variability metric must be sensitive to known deviations in waveform amplitude, duration, and overall shape, without being biased by waveforms that have both positive and sub-atmospheric pressure profiles. Through systematic analysis of model waveforms, we found a coefficient of variability (CV) parameter on waveforms adjusted such that the overall mean was 0 to be best suited for swallowing pressure variability analysis. We then investigated pharyngeal swallowing pressure variability using high-resolution manometry data from healthy individuals to assess impacts of waveform alignment, pharyngeal region, and number of swallows investigated. The alignment that resulted in the lowest overall swallowing pressure variability was when the superior-most sensor in the upper esophageal sphincter reached half its maximum pressure. Pressures in the tongue base region of the pharynx were least variable and pressures in the hypopharynx region were most variable. Sets of 3 - 10 consecutive swallows had no overall difference in variability, but sets of 2 swallows resulted in significantly less variability than the other dataset sizes. This study identified variability in swallowing pressure waveform shape throughout the pharynx in healthy adults; we discuss implications for swallowing motor control.