Modulation of the stretch reflex during volitional sinusoidal tracking in Parkinson's disease

Objective Assessment of Bradykinesia Estimated from the Wrist Extension in Older Adults and Patients with Parkinson's Disease

Parkinson's disease (PD) presents several motor signs, including tremor and bradykinesia. However, these signs can also be found in other motor disorders and in neurologically healthy older adults. The incidence of bradykinesia in PD is relatively high in all stages of the disorder, even when compared to tremor. Thus, this research proposes an objective assessment of bradykinesia in patients with PD (G _PD: 15 older adults with Parkinson's disease, 65.3 ± 9.1 years) and older adults (G _HV: 12 healthy older adults, 60.1 ± 6.1 years). The severity of bradykinesia in the participants of G _PD was assessed using the Unified Parkinson's Disease Rating Scale. Movement and muscular activity were detected by means of inertial (accelerometer, gyroscope, magnetometer) and electromyographic sensors while the participants performed wrist extension against gravity with the forearm on pronation. Mean and standard error of inertial and electromyographic signal parameters could discriminate PD patients from healthy older adults (p value <0.05). In discriminating patients with PD from healthy older adults, the mean sensitivity and specificity were respectively 86.67 and 83.33%. The discrimination between the groups, based on the objective evaluation of bradykinesia, may contribute to the accurate diagnosis of PD and to the monitoring of therapies to control parkinsonian bradykinesia, and opens the possibility for further comparative studies considering individuals suffering from other motor disorders.

Pathophysiology of Motor Dysfunction in Parkinson's Disease as the Rationale for Drug Treatment and Rehabilitation

Cardinal motor features of Parkinson's disease (PD) include bradykinesia, rest tremor, and rigidity, which appear in the early stages of the disease and largely depend on dopaminergic nigrostriatal denervation. Intermediate and advanced PD stages are characterized by motor fluctuations and dyskinesia, which depend on complex mechanisms secondary to severe nigrostriatal loss and to the problems related to oral levodopa absorption, and motor and nonmotor symptoms and signs that are secondary to marked dopaminergic loss and multisystem neurodegeneration with damage to nondopaminergic pathways. Nondopaminergic dysfunction results in motor problems, including posture, balance and gait disturbances, and fatigue, and nonmotor problems, encompassing depression, apathy, cognitive impairment, sleep disturbances, pain, and autonomic dysfunction. There are a number of symptomatic drugs for PD motor signs, but the pharmacological resources for nonmotor signs and symptoms are limited, and rehabilitation may contribute to their treatment. The present review will focus on classical notions and recent insights into the neuropathology, neuropharmacology, and neurophysiology of motor dysfunction of PD. These pieces of information represent the basis for the pharmacological, neurosurgical, and rehabilitative approaches to PD.

“Abnormal” movements: What are they reflections of?

We agree with Latash & Anson that therapeutic approaches should be directed toward solving the underlying problem, not toward adapting the abnormal to normal behaviour. The fundamental obstacle, however, is that doing so requires a solution of the “equivalence problem” in movement control.

Defective preprogramming does not account for the clinical deficits of Parkinson's disease

Latash & Anson argue that changed motor patterns should not be viewed as pathological. Instead, they should be viewed as adaptations to a primary deficit. We argue that the evidence shows: (1) bradykinesia is not an adaptation to a different primary deficit, and (2) bradykinetic movements are not “normal” slowed movements but, to the contrary, bradykinesia is part of the pathophysiology of Parkinson's disease.

Generic mechanisms of coordination in special populations

We show that left-handers can be considered as a “special” population. We indicate that the asymmetries in performance exhibited by left-handers are due to a basic asymmetry in the underlying coordination dynamics that constrains bimanual coordination. In contrast to the claims of Latash & Anson, we argue that considerable knowledge has been gained regarding the essential equations of motion that govern biological coordination.

“Normal” is not the issue: It is “effective” goal attainment that counts

Adaptive motor patterns that emerge after a neuromusculoskeletal lesion reflect not only the primary lesion, but also the dynamic characteristics of the musculoskeletal linkage and environment in which the action is performed. Although these patterns may be optimal, they may also be ineffective as goal-directed actions; effectiveness may only be regained if training addresses primary deficits and ensures practice without gross biomechanical adaptations.

The goal of treatment for motor impairment is not to “normalize” but to “functionalize” through facilitative modulation and enabling context

Adaptations occurring in the central nervous system (CNS) in the presence of pathology are not uniformly “good” for the organism when viewed in a functional context. A functional reordering of CNS priorities can be produced by allowing restructuring of the external context or through modification of neuromuscular physiology or anatomy designed to reduce the inherent restriction of functional movement in upper motor neuron syndrome. In fact, volitional control can often be “unmasked” through such interventions. Therapeutic interventions should not be directed toward “normalization” of motor patterns but should permit a functional reordering of CNS priorities that would otherwise not be possible.

What are “normal movements” in atypical populations?

Redundancy of the motor control system is an important feature that gives the central control structures options for solving everyday motor problems. The choice of particular control patterns is based on priorities (coordinative rules) that are presently unknown. Motor patterns observed in unimpaired young adults reflect these priorities. We hypothesize that under certain atypical conditions, which may include disorders in perception of the environment and in decision making, structural or biochemical changes within the central nervous system (CNS), and/or structural changes of the effectors, the central nervous system may reconsider its priorities. A new set of priorities will reflect the current state of the system and may lead to different patterns of voluntary movement. Under such conditions, changed motor patterns should be considered not pathological but rather adaptive to a primary disorder and may even be viewed as optimal for a given state of the system of movement production. Therapeutic approaches should not be directed toward restoring the motor patterns to as close to “normal” as possible but rather toward resolving the original underlying problem. We illustrate this approach using, as examples, movements in amputees, in patients with Parkinson's disease, in patients with dystonia, and in persons with Down syndrome.

What are “normal movements” inanypopulation?

It is the contention of Latash & Anson (L&A) that in atypical populations, such as those with cognitive, central neurological, or peripheral disorders, the central nervous system (CNS) is capable of producing more effective, though often less “normal,” movement patterns ifleft to its own devices. It is the aim of this commentary to extend their argument to other populations by pointing out the many parallels with development of movement patterns in sport.

Should stereotypic movement synergies in hemiparetic patients be considered adaptive?

The motor deficits observed in patients following some lesions of the central nervous system may be viewed as falling at one extreme of the continuum of possible motor behaviours. They are usually associated with an impaired ability to select and control specific movements from the available repertoire. Such movements may not be viewed as abnormal. However, it is unlikely that the primary motor deficits can all be considered adaptive.

“Constraint” versus “choice” in preferred movement patterns

Movement patterns in impaired gait are not selected by a smart central nervous system (CNS), but arise by virtue of mutual constraints of task, limitations in personal dynamics available for the task, and optimality criteria. An oscillatory model of gait cycle is presented that exemplifies this control and coordination scheme. Preferred gait patterns may be based on physical principles rather than CNS “coordinative rules.”

Developmental “movement disorders” and problem solving

Normal infants show a wide range of “atypical” movements. These, like the movements of atypical and normal adults, are best characterized as solutions to motor problems. Motor patterns alone may not be precise indicators of neurological status.

Is motor pathology associated with setting new CNS priorities or with increased difficulty in overcoming or suppressing preexisting CNS priorities?

Whereas Latash & Anson (L&A) have underscored the rearrangement or setting of new priorities, our primary focus is on preexisting central nervous system (CNS) priorities that become even more prevalent and intrusive under pathological conditions. The adaptations observed in the disordered motor system can often be understood against the backdrop of these primary CNS constraints. Even though this perspective has not been specifically addressed in the target article, we consider it complementary and not necessarily in opposition to L&A's primary thesis.

Velocity control in Parkinson's disease: a quantitative analysis of isochrony in scribbling movements

An experiment was conducted to contrast the motor performance of three groups (N = 20) of participants: (1) patients with confirmed Parkinson Disease (PD) diagnose; (2) age-matched controls; (3) young adults. The task consisted of scribbling freely for 10 s within circular frames of different sizes. Comparison among groups focused on the relation between the figural elements of the trace (overall size and trace length) and the velocity of the drawing movements. Results were analysed within the framework of previous work on normal individuals showing that instantaneous velocity of drawing movements depends jointly on trace curvature (Two-thirds Power Law) and trace extent (Isochrony principle). The motor behaviour of PD patients exhibited all classical symptoms of the disease (reduced average velocity, reduced fluency, micrographia). At a coarse level of analysis both isochrony and the dependence of velocity on curvature, which are supposed to reflect cortical mechanisms, were spared in PD patients. Instead, significant differences with respects to the control groups emerged from an in-depth analysis of the velocity control suggesting that patients did not scale average velocity as effectively as controls. We factored out velocity control by distinguishing the influence of the broad context in which movement is planned--i.e. the size of the limiting frames--from the influence of the local context--i.e. the linear extent of the unit of motor action being executed. The balance between the two factors was found to be distinctively different in PD patients and controls. This difference is discussed in the light of current theorizing on the role of cortical and sub-cortical mechanisms in the aetiology of PD. We argue that the results are congruent with the notion that cortical mechanisms are responsible for generating a parametric template of the desired movement and the BG specify the actual spatio-temporal parameters through a multiplicative gain factor acting on both size and velocity.

Quantification of intrinsic and reflexive properties during multijoint arm posture

This study estimates intrinsic and reflexive properties of single- and two-joint muscles acting around the human shoulder, elbow and wrist joint during posture maintenance. External force disturbances were applied to the hand while subjects (n = 5) were instructed to minimize their hand displacement amplitude in a horizontal plane. To examine how the nervous system modifies intrinsic and reflexive muscle properties, we varied external damping, disturbance power and arm configuration. A new identification method is introduced to quantify a large set of model parameters describing intrinsic, activation and reflexive properties, the latter representing afferent feedback gains from muscle spindles and Golgi tendon organs. Consistent estimates were found for the gains of the different types of reflex pathways. The results showed that intrinsic visco-elasticity of shoulder muscles was minimal, whereas reflexive feedback was largest compared to the elbow and wrist joint. Intrinsic and reflexive properties of the two-joint shoulder-elbow muscles were larger than the two-joint elbow-wrist muscles. Contrasting to previous single-joint studies, the reflex gains did not vary with the experimental conditions. It is concluded that during redundant multijoint posture maintenance, the mechanical properties are efficiently controlled on the joint level and not on the endpoint level.

Paradoxical modulation of tendon tap reflex during voluntary contraction in Parkinson's disease

OBJECTIVE

Inadequate supraspinal modulation of spinal motor control mechanisms such as alpha-gamma coactivation is supposed to cause difficulty in maintaining proper voluntary contraction in Parkinson's disease (PD).

METHODS

Subjects were 42 patients with PD and 20 normal volunteers. Soleus H-reflex and tendon tap reflex (T-reflex) were recorded. The maximal reflexes (H(max) and T(max)) at rest were recorded first. Next, the stimulus intensities were fixed to obtain a reflex size of around 25% of M(max) at rest for both H- and T-reflexes, and the reflexes were recorded at rest, during tonic plantarflexion (TPF), and at the onset of plantarflexion.

RESULTS

H(max) at rest was 55% and T(max) 30% in normal subjects, while they were 36 and 31%, respectively, in PD. The size ratio of T(max) and H(max) at rest in PD was larger than normal. In PD, the size of H-reflex increased with TPF as in normal subjects, but T-reflex decreased. These changes in T-reflex were correlated with the grade of rigidity, bradykinesia, and time for 10 m gait. H-reflex had no such correlations.

CONCLUSIONS

T-reflex was abnormally modulated in PD especially during tonic contraction.

SIGNIFICANCE

Inappropriate supraspinal modulation of the spinal reflex pathways disturbs motor performance in PD.

Phase-dependent and task-dependent modulation of stretch reflexes during rhythmical hand tasks in humans

Phase-dependent and task-dependent modulation of reflexes has been extensively demonstrated in leg muscles during locomotory activity. In contrast, the modulation of reflex responses of hand muscles during rhythmic movement is poorly documented. The objective of this study was to determine whether comparable reflex modulation occurs in muscles controlling finger motions during rhythmic, fine-motor tasks akin to handwriting. Twelve healthy subjects performed two rhythmic tasks while reflexes were evoked by mechanical perturbations applied at various phases of each task. Electromyograms (EMGs) were recorded from four hand muscles, and reflexes were averaged during each task relative to the movement phase. Stretch reflexes in all four muscles were found to be modulated in amplitude with respect to the phase of the rhythmic tasks, and also to vary distinctly with the tasks being conducted. The extent and pattern of reflex modulation differed between muscles in the same task, and between tasks for the same muscle. Muscles with a primary role in each task showed a higher correlation between reflex response and background EMG than other muscles. The results suggest that the modulation patterns observed may reflect optimal strategies of central-peripheral interactions in controlling the performance of fine-motor tasks. As with comparable studies on locomotion, the phase-dependency of the stretch reflexes implies a dynamically fluctuating role of proprioceptive feedback in the control of the hand muscles. The clear task-dependency is also consistent with a dynamic interaction of sensory feedback and central programming, presumably adapted to facilitate the successful performance of the different fine-motor tasks.

The basal ganglia network mediates the planning of movement amplitude

This study addresses the hypothesis that the basal ganglia (BG) are involved specifically in the planning of movement amplitude (or covariates). Although often advanced, based on observations that Parkinson's disease (PD) patients exhibit hypokinesia in the absence of significant directional errors, this hypothesis has been challenged by a recent alternative, that parkinsonian hypometria could be caused by dysfunction of on-line feedback loops. To re-evaluate this issue, we conducted two successive experiments. In the first experiment we assumed that if BG are involved in extent planning then PD patients (who exhibit a major dysfunction within the BG network) should exhibit a preserved ability to use a direction precue with respect to normals, but an impaired ability to use an amplitude precue. Results were compatible with this prediction. Because this evidence did not prove conclusively that the BG is involved in amplitude planning (functional deficits are not restricted to the BG network in PD), a second experiment was conducted using positron emission tomography (PET). We hypothesized that if the BG is important for planning movement amplitude, a task requiring increased amplitude planning should produce increased activation in the BG network. In agreement with this prediction, we observed enhanced activation of BG structures under a precue condition that emphasized extent planning in comparison with conditions that emphasized direction planning or no planning. Considered together, our results are consistent with the idea that BG is directly involved in the planning of movement amplitude or of factors that covary with that parameter.

Basal ganglia network mediates the control of movement amplitude

In the present study we address the hypothesis that the basal ganglia are specifically involved in the planning of movement amplitude (or related covariates). This prediction has often been put forward based on the observation that Parkinson's disease (PD) patients exhibit hypokinesia. A close examination of the literature shows, however, that this commonly reported clinical symptom is not consistently echoed by experimental observations. When required to point to visual targets in the absence of vision of the moving limb, PD subjects exhibit various patterns of inaccuracy, including hypometria, hypermetria, systematic direction bias, or direction-dependent errors. They have even been shown to be as accurate as healthy, age-matched subjects. The main aim of the current study is to address the origin of these inconsistencies. To this end, we required nine patients presenting with advanced PD and 15 age-matched control subjects to perform planar reaching movements to visual targets. Eight targets were presented in equally spaced directions around a circle centered on the hand's starting location. Based on a previously validated parsing procedure, end-point errors were segmented into localization and planning errors. Localization errors refer to the existence of systematic biases in the estimation of the initial hand location. These biases can potentially transform a simple pattern of pure amplitude errors into a complex pattern involving both amplitude and direction errors. Results indicated that localization errors were different in the PD patients and the control subjects. This is not surprising knowing both that proprioception is altered in PD patients and that the ability to locate the hand at rest relies mainly on the proprioceptive sense, even when vision is available. Unlike normal subjects, localization errors in PD were idiosyncratic, lacking a consistent pattern across subjects. When the confounding effect of initial hand localization errors was canceled, we found that end-point errors were only due to the implementation of an underscaled movement gain (15%), without direction bias. Interestingly, the level of undershoot was found to increase with the severity of the disease (inferred from the Unified Parkinson's Disease Rating Scale, UPDRS, motor score). We also observed that movement variability was amplified (32%), but only along the main movement axis (extent variability). Direction variability was not significantly different in the patient population and the control group. When considered together, these results support the idea that the basal ganglia are specifically involved in the control of movement amplitude (or of some covariates). We propose that this structure participates in extent planning by modulating cortical activity and/or the tuning of the spinal interneuronal circuits.

Joint torques during sit-to-stand in healthy subjects and people with Parkinson's disease

OBJECTIVES

To compare lower limb joint torques during sit-to-stand in normal elderly subjects and people with Parkinson's disease, using a developed biomechanical model simulating all phases of sit-to-stand.Design. A cross-sectional study utilizing a Parkinsonian and a control group.

BACKGROUND

Subjects with Parkinson's disease were observed to experience difficulty in performing sit-to-stand. The developed model was used to calculate the lower limb joint torques in normal elderly subjects and subjects with Parkinson's disease, to delineate possible causes underlying difficulties in initiating sit-to-stand task.

METHODS

Six normal elderly subjects and seven age-matched subjects with Parkinson's disease performed five sit-to-stand trials at their self-selected speed. Anthropometric data, two-dimensional kinematic and foot-ground and thigh-chair reactive forces were used to calculate, via inverse dynamics, the joint torques during sit-to-stand in both before and after seat-off phases. The difference between the control and Parkinson's disease group was analysed using independent t-tests.

RESULTS

Both control and Parkinson's disease groups had a similar joint kinematic pattern, although the Parkinson's disease group demonstrated a slower angular displacement. The latter subjects produced significantly smaller normalized hip flexion torque and presented a slower torque build-up rate than the able-bodied subjects (P<0.05).

CONCLUSION

Slowness of sit-to-stand in people with Parkinson's disease could be due to a reduced hip flexion joint torque and a prolonged rate of torque production.

Switching of movement direction is central to parkinsonian bradykinesia in sit-to-stand

Patients with Parkinson's disease (PD) are known to manifest slowness in movements. We sought to identify the particular kinematic and kinetic disorders that contribute to the slowness in performing sit-to-stand in these patients. Two inter-related studies were carried out. In the first study, 20 patients with PD and 20 control subjects were instructed to perform sit-to-stand at a natural speed. In the second study, 15 control subjects were instructed to simulate the slower speed of sit-to-stand of the patients identified in the first study. Kinematic and kinetic data were recorded by a PEAK motion analysis system and two force platforms. The results showed that patients with PD generated smaller peak horizontal and vertical velocities during the task. They took a longer time to complete each individual phase as well as the whole movement of sit-to-stand. Patients also produced smaller peak hip flexion and ankle dorsiflexion joint torques and had prolonged time-to-peak torques from sit-to-stand onset. When control subjects simulated the patients' speed of sit-to-stand, there was no difference in all the kinematic and kinetic data between groups. The only exception was that they exhibited a shorter transition time between peak horizontal velocity (flexion phase) and seat-off (extension phase) than the patients. This study demonstrated that the slowness of PD patients during sit-to-stand at a natural speed could be attributed to inadequate peak hip flexion and ankle dorsiflexion torques, a prolonged torque production, as well as a difficulty in switching from the flexion to extension direction during sit-to-stand. As the latter difficulty persisted when the control subjects performed the task at a speed similar to that of the patients, our findings suggest that a fundamental problem of patients with Parkinson's disease could be a switch between movement directions.

Relationship between the degree of inhibited stretch reflex activities of the wrist flexor and reaction time during quick extension movements

It has been reported that stretch reflex responses, including the long latency component, are modulated by motor preparation for the direction and type of movement. In the present study, human subjects were required to make a reaction movement in the direction of the wrist extension following a muscle stretch to the wrist flexor, and we investigated the relationship between the modulation of reflex activities of the wrist flexor and the length of reaction time (premotor time) of the wrist extensor. Twenty-five healthy males, ranging in age from 20 to 28, participated in the experiments. A DC torque motor was used to evoke the reflex EMG responses on the flexor. Averaging the rectified EMG, recorded with the surface electrodes over the flexor, showed short and long latency reflexes (M1 and M2 components) in response to the muscle stretch. For all subjects, the amplitudes of the reflex components during the extension reaction movement decreased, compared to those amplitudes in the non-reaction tasks. The decrease in the M2 component, which is considered a transcortical reflex, was significantly larger than the decrease in the M1 component, which is a spinal reflex. Moreover, there were correlations between reaction time to muscle stretch and the degree of decrease in reflex activities with the extension reaction (r = 0.652 for M1, r = 0.813 for M2, P < 0.01). It became clear that the subjects with shorter reaction times inhibited their reflex activities of the flexor, particularly the M2 component which prevents the extension movement, to a greater degree than the subjects with longer reaction times. Therefore, our results suggest that the degree of M2 modulation directly reflects the individual motor control required to perform quick movements.

Measurement of rigidity in Parkinson's disease

Clinical assessment of rigidity in parkinsonian patients is largely qualitative. The reliability and validity of the assessments are sometimes in doubt. Several "engineering" methods of quantifying rigidity have been described, but none has been adopted into general clinical practice. A possible reason is that these methods differ in crucial aspects from the clinical exam. We therefore tackled the problem by monitoring the clinical exam itself, using small sensors to measure the forces and displacements applied. Limb impedance (Z) was computed using parameter identification methods and compared to raters' verbalized ratings of rigidity based on a 5-point scale: the Unified Parkinson's Disease Rating System. The qualitative and quantitative estimates of impedance covaried over a fourfold range, depending on the forces imposed and the subject's motor set. Raters differed by up to 1 full point in their mean qualitative ratings and sometimes disagreed on whether levodopa reduced rigidity. This was not due to any significant differences in the overall range of rigidity they evoked, but rather to the way they scored this range [the ratio of mean rating to mean impedance (R/Z) varied between raters and subjects]. On the other hand, the R/Z ratio was reproducible over separate sets of ratings and may therefore serve to convert measured impedance into a standardized rating. Our results indicate that the current clinical exam may be too abbreviated to detect the sometimes quite small reductions in rigidity after levodopa. We conclude that a device that conveniently quantifies the clinical assessment of rigidity is now available and will lead to more standardized protocols for rating rigidity in the near future.

Reciprocal inhibition in Parkinson's disease

We studied the inhibition of median H-reflex by conditioning stimuli on the radial nerve in 14 normal controls, 6 patients with unilateral and 1 patient with predominantly left-sided Parkinson's disease. In normal controls, the electrophysiological studies were performed on their right hands, yet both hands were examined in patient group. In the controls, we identified three inhibitory phases, with maximal inhibition at conditioning-test intervals of 0 ms (41.66 +/- 4.73%), 20 ms (45.19 +/- 4.33%), and 100 ms (44.55 +/- 6.84%), respectively. In the less- or a- symptomatic side of the patient group, the inhibitory patterns are similar to those of the controls. However, in the symptomatic arms, loss of inhibition, or even mild potentiation, was observed in the third inhibitory phase. When the symptomatic and asymptomatic sides of patients were compared, in contrast to the striking phenomenon found between symptomatic side and the controls, no difference was observed in the third phase. The current results imply that, although no obvious rigidity can be detected on the asymptomatic sides, subtle functional corruption may have occurred within the contralateral basal ganglia in patients with unilateral Parkinson's disease. The remarkable change of the third phase on the symptomatic sides of patients suggests the perturbation of the polysynaptic long latency reflex pathway may somehow play a role in the rigidity pathogenesis.

Thought is action

It is difficult to chart “normal movements” in atypical populations, such as those with Parkinson's disease, because there is great variability in the pattern of motor changes, both within and between patients. However, the potential clinical implications of Latash & Anson's theme are positive and powerful.

When are adaptive motor patterns nonadaptive?

The assumption that adaptive changes in motor patterns are optimal is questioned. Instances are cited where alteration of the adaptive motor patterns may be warranted. Other issues discussed are: (1) the relationship between central nervous system (CNS) priorities and the individual's priorities, (2) the use of cognitive bypass strategies by impaired individuals, and (3) conceiving CNS priorities as coordinative rules.

Dynamic similarities in action systems

Latash & Anson's contention that movement patterns that are different from those typically observed in persons without impairments should not be considered abnormal and usually should not be corrected is consistent with Davis & Burton's Ecological Task Analysis (ETA). Extending from the ETA concept of performer-scaled performance measures, the use of Froude numbers may offer insight into the global dynamics of a person's action system.

On optimality and movement disorders: A dynamic systems perspective

The argument that disordered or changed motor patterns can be adaptive or optimal given the constraints imposed is supported. Two major points of criticism are made, concerning the perceived superstates of the primary disorder and the absence of a systematic approach to identifying this adaptivity and optimality. We have tried to give the general outlines of such an approach to disordered movements from a dynamic systems perspective.

Bradykinesia in Parkinson's disease and cocontraction activity in dystonia are unlikely to be due to adaptive changes in the CNS

Latash & Anson's explanation of bradykinesia in patients with Parkinson's disease and cocontraction in dystonic patients is intriguing. However, the proposed adaptive changes in the central nervous system do not fit well with both clinical and experimental evidence of motor impairment in these patients. In particular, we question the explanation of: (1) the role of postural reactions and spatial accuracy in bradykinesia, (2) certain abnormalities during the execution of sequential and simultaneous movements, (3) the sudden changes in mobility (ON and OFF) of Parkinsonian patients, and (4) the meaning of reflex circuitry changes in dystonia.

Evaluation of central commands: Toward a theoretical basis for rehabilitation

The commentary focuses on the need for motor control modeling as a rationale for rehabilitation. We give examples in a bimanual unloading task and examine the potential consequences for recovery in patients with cerebral lesions. Hierarchical models of motor control lead to a distinction between “task optimization” and “motor optimization” and to a qualifier on Latash & Anson's “hands-off” position.

Toward peaceful coexistence of adaptive central strategies and medical professionals

We start with a number of philosophical and theoretical issues related to motor control, proceed through a spectrum of problems related to the role of adaptive changes in the central nervous system (CNS) in response to a primary disorder, and end with tentative practical recommendations. We consider the hierarchical and dynamic approaches to motor control not as incompatible alternatives but as ways of approaching two equally important issues, those of control and coordination. Professionals working in the area of physical therapy and rehabilitation should make use of the adaptive abilities of the CNS, identify goals, provide tools, and allow the CNS to develop optimal strategies. Therapists should intervene if they suspect that the CNS settles down in a local rather than a global optimum because of such factors as pain or the lack of a long-term predictive ability. Adaptive changes within the CNS may be important not only in pathologies but also in cases of specialized training, normal growth, and normal ageing.

Rehabilitation promotes functional movement in atypical populations

The suggestion that movement disorders exhibited by people with central nervous system (CNS) dysfunction should be considered normal and therefore not rehabilitated is rejected from three standpoints: (1) the CNS does not always select the best movement patterns for optimal long term outcome, (2) there is literature demonstrating that rehabilitation enhances motor function and independence, and (3) there exists a capacity for motor recovery and motor skill learning following brain damage.

Posturo-kinetic capacity in the disabled

“Normal movements” in atypical populations address the question of postural control: Voluntary movement is a perturbation of body balance and cannot be executed without a convenient counterperturbation. Despite a change in the postural program in relation to the impairment (Parkinson's disease, paraplegia), the performance level is decreased. Movements are not “normal,” owing to a reduction in posturokinetic capacity.

What is the appropriate criterion for therapeutic intervention in the motor domain?

Observations are made on Latash & Anson's theme that changed motor patterns should not be viewed as pathological. Normality in motor control might be characterised in terms of qualitative differences in control mechanisms rather than differences in movement patterns. Understanding of the concepts implicit in instructions to subjects should be confirmed. Principles of energy expenditure in atypical movements are outlined. If restoration of normality is not adopted as a criterion for therapeutic intervention, what might be proposed as an alternative?

Altered bilateral muscle synergies after stroke

Using movement disorders to understand the central nervous system's goals for motor behaviour may be easier in neurological models with a focal lesion of sudden onset, because the distinction between primary and adaptive changes may be clearer than in slowly progressive and/or diffuse neurological disease.

What makes a population atypical–priorities or constraints?

Priorities for movement reflect constraints deriving from the motor system, task goals, and physical environment. Atypical and typical populations alike set and reset priorities in response to constraints, and they do so at many processing loci and time scales. Efforts to understand what is atypical about a population should focus first on the constraints it encounters.

Anticipatory postural mechanisms: Some evidence and methodological implications

To understand the basic priorities of the central nervous system in human motor control, neurophysiological parameters are important. Certain H-reflex methods related to anticipatory postural control are particularly useful and may have therapeutic implications.

The concept of “normal” movement and its consequences for therapy

The guideline for therapy should be the improvement of the individual's functionality, not the acquisition of the ill-defined “goldstandard” of normal movement. However, Latash & Anson's suggestion that only primary causes of dysfunction should be treated is problematic for two reasons: First, the distinction between genuine and adaptive changes in motor performance is not always possible, and second, adaptive changes do not necessarily improve motor function, but may actually be detrimental to the system's performance.

Towards functional movement: Implications for research and therapy

Researchers and clinicians have different goals and constraints in trying to understand and treat movement disorders. Research on primary and secondary aspects of disorders may lead to effective treatment aimed at restoring functional movements even if the primary disorder cannot be cured. Similarly, movement patterns may be maladaptive and hence need therapeutic intervention to restore functional movement skills.

Frames of reference and normal movement

Latash & Anson propose that so-called abnormal movements may be stable and adaptive coordination and control solutions to task goals in action. Their interpretation of this established viewpoint is confused throughout in the persistent crossing of frames of reference, both in the description of movement and action and the proposed theory for motor control.

Adaptive changes in postural reactions after unilateral leg amputation

Changes in anticipatory postural adjustment following below-the-knee amputation may be considered as adaptive for reacquiring balance control.

How functional are atypical motor patterns?

Latash & Anson are commended for pointing out that investigators of atypical motor performance have too often failed to recognize the adaptive nature of many atypical movement characteristics. However, the authors' assumption that atypical motor patterns can be considered “normal” and, by implication, that it is futile to attempt to teach different patterns to patients that may be more functional, is criticized.

Anthropomorphizing the CNS: Is it what or who you know?

The target article pays insufficient attention to (1) the difficulties that arise when the term “normal” is used to describe motor skill behavior, and (2) the need to resist ascribing motor control to an intelligent central nervous system. A complex systems perspective is proposed with attractor states and periodicity identified as markers of atypical coordination and control.

Optimal search strategies for optimal motor solutions: Self-determination or informed guidance?

Impoverished resources may direct the pathologic central nervous system toward local solutions during ontogeny. The resultant motor behavior can be systemically optimal without being functionally optimal. Therapeutic intervention should focus on facilitating function (rather than “normalcy”) by encouraging behavioral exploration through appropriate combinations of task and environmental variations with respect to individual capabilities. Some health professions have already adopted this philosophy.

Abnormal movements can be identified in “atypical” populations

Latash & Anson's discussion of movements of “atypical” populations is potentially topical but unhelpful. Abnormal movements can be distinguished from any compensatory adjustments in Parkinson's, Huntington's, and Alzheimer's diseases and schizophrenia. To suggest otherwise may do “atypical” populations and their caregivers a disservice. It would be more meaningful to discuss the relative modularity and separability of cognitive and motor processes.

Strength in Parkinson's disease: relationship to rate of force generation and clinical status

Maximum elbow flexor and extensor muscle strength was measured in 9 patients with Parkinson's disease on and off antiparkinsonian medication. In addition, the rate of force generation, the rate of actively returning force to resting levels, and passive release of force "relaxation" were measured in submaximal contractions. The measures of strength and contraction time were correlated with changes in clinical status as measured by the Unified Parkinson's Disease Rating Scale. When patients were off medication, their reduction in strength was significantly greater in extension than flexion. The reduction in flexion strength did not reach statistical significance. The extensor weakness was primarily due to decreased tonic activation of the extensor muscles and not to muscle coactivation. Muscle relaxation time was much more prolonged than was force generation time or active force return time. The increase in relaxation time and the decrease in extensor strength both correlated with changes in clinical status. Finally, changes in extensor torque correlated with the time to actively return force, suggesting that reduced strength is related to a reduced ability to generate rapid contractions in some patients with Parkinson's disease. These results suggest that there is an asymmetric distribution of muscle weakness in Parkinson's disease and that selected measures of muscle strength and muscle relaxation correlate with changes in clinical status.