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Dysfunction of the Lenticular Nucleus Is Associated with Dystonia in Wilson's Disease. Brain Sci 2022; 13:brainsci13010007. [PMID: 36671989 PMCID: PMC9856696 DOI: 10.3390/brainsci13010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/27/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Dysfunction of the lenticular nucleus is thought to contribute to neurological symptoms in Wilson's disease (WD). However, very little is known about whether and how the lenticular nucleus influences dystonia by interacting with the cerebral cortex and cerebellum. To solve this problem, we recruited 37 WD patients (20 men; age, 23.95 ± 6.95 years; age range, 12-37 years) and 37 age- and sex-matched healthy controls (HCs) (25 men; age, 25.19 ± 1.88 years; age range, 20-30 years), and each subject underwent resting-state functional magnetic resonance imaging (RS-fMRI) scans. The muscle biomechanical parameters and Unified Wilson Disease Rating Scale (UWDRS) were used to evaluate the level of dystonia and clinical representations, respectively. The lenticular nucleus, including the putamen and globus pallidus, was divided into 12 subregions according to dorsal, ventral, anterior and posterior localization and seed-based functional connectivity (FC) was calculated for each subregion. The relationships between FC changes in the lenticular nucleus with muscle tension levels and clinical representations were further investigated by correlation analysis. Dystonia was diagnosed by comparing all WD muscle biomechanical parameters with healthy controls (HCs). Compared with HCs, FC decreased from all subregions in the putamen except the right ventral posterior part to the middle cingulate cortex (MCC) and decreased FC of all subregions in the putamen except the left ventral anterior part to the cerebellum was observed in patients with WD. Patients with WD also showed decreased FC of the left globus pallidus primarily distributed in the MCC and cerebellum and illustrated decreased FC from the right globus pallidus to the cerebellum. FC from the putamen to the MCC was significantly correlated with psychiatric symptoms. FC from the putamen to the cerebellum was significantly correlated with muscle tension and neurological symptoms. Additionally, the FC from the globus pallidus to the cerebellum was also associated with muscle tension. Together, these findings highlight that lenticular nucleus-cerebellum circuits may serve as neural biomarkers of dystonia and provide implications for the neural mechanisms underlying dystonia in WD.
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The immediate effect of different loads does not alter muscle co-activation of the upper limb in young adults with dyskinetic cerebral palsy. Gait Posture 2021; 90:161-166. [PMID: 34482220 DOI: 10.1016/j.gaitpost.2021.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 08/13/2021] [Accepted: 08/24/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is insufficient information on muscle co-activation in the upper limbs to help healthcare providers develop treatment programs for patients with dyskinetic cerebral palsy (DCP). RESEARCH QUESTION Is the degree of muscle co-activation greater in adults with DCP than in healthy individuals? Does the use of different arm weights modify co-contraction in individuals with PCD? METHODS Fourteen healthy individuals (control group [CG]) and 14 individuals with DCP (dyskinetic group [DG]) participated in the study. The degree of muscle co-activation of the dominant limb during drinking from a mug was compared between the two groups. The task was divided into a going, adjusting, and returning phase. In the DG, an analysis was also performed on using an arm weight during the functional task. The loads corresponded to 10, 20, and 30 % of maximum isometric muscle strength measured in each participant. RESULTS In comparing the two groups, the DG exhibited a greater muscle co-activation in the shoulder and elbow muscles during the going phase, the shoulder, elbow, and wrist during the adjusting phase; and the elbow during the returning phase. The DG also showed a greater mean index of curvature (MIC), time to perform the movement phases, and lesser mean velocity (Vm) to drinking. In analyzing the DG's arm weight, no effect on co-activation, MIC, time to perform the movement phases, and Vm to drinking were found with the loads tested (p > 0.05). CONCLUSION Muscle co-activation is increased in adults with DCP in comparison to healthy individuals. Moreover, arm weight during the functional activity of drinking from a mug did not alter co-activation, although an immediate effect was expected.
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Cappellini G, Sylos-Labini F, MacLellan MJ, Assenza C, Libernini L, Morelli D, Lacquaniti F, Ivanenko Y. Locomotor patterns during obstacle avoidance in children with cerebral palsy. J Neurophysiol 2020; 124:574-590. [DOI: 10.1152/jn.00163.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Previous studies mainly evaluated the neuromuscular pattern generation in cerebral palsy (CP) during unobstructed gait. Here we characterized impairments in the obstacle task performance associated with a limited adaptation of the task-relevant muscle module timed to the foot lift during obstacle crossing. Impaired task performance in children with CP may reflect basic developmental deficits in the adaptable control of gait when the locomotor task is superimposed with the voluntary movement.
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Affiliation(s)
- G. Cappellini
- Laboratory of Neuromotor Physiology, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) Santa Lucia Foundation, Rome, Italy
- Department of Pediatric Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - F. Sylos-Labini
- Laboratory of Neuromotor Physiology, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) Santa Lucia Foundation, Rome, Italy
| | - M. J. MacLellan
- Department of Applied Human Sciences, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - C. Assenza
- Department of Pediatric Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - L. Libernini
- Department of Pediatric Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - D. Morelli
- Department of Pediatric Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - F. Lacquaniti
- Laboratory of Neuromotor Physiology, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) Santa Lucia Foundation, Rome, Italy
- Centre of Space Bio-medicine and Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Y. Ivanenko
- Laboratory of Neuromotor Physiology, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) Santa Lucia Foundation, Rome, Italy
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Haberfehlner H, Goudriaan M, Bonouvrié LA, Jansma EP, Harlaar J, Vermeulen RJ, van der Krogt MM, Buizer AI. Instrumented assessment of motor function in dyskinetic cerebral palsy: a systematic review. J Neuroeng Rehabil 2020; 17:39. [PMID: 32138731 PMCID: PMC7057465 DOI: 10.1186/s12984-020-00658-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 02/13/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In this systematic review we investigate which instrumented measurements are available to assess motor impairments, related activity limitations and participation restrictions in children and young adults with dyskinetic cerebral palsy. We aim to classify these instrumented measurements using the categories of the international classification of functioning, disability and health for children and youth (ICF-CY) and provide an overview of the outcome parameters. METHODS A systematic literature search was performed in November 2019. We electronically searched Pubmed, Embase and Scopus databases. Search blocks included (a) cerebral palsy, (b) athetosis, dystonia and/or dyskinesia, (c) age 2-24 years and (d) instrumented measurements (using keywords such as biomechanics, sensors, smartphone, and robot). RESULTS Our search yielded 4537 articles. After inspection of titles and abstracts, a full text of 245 of those articles were included and assessed for further eligibility. A total of 49 articles met our inclusion criteria. A broad spectrum of instruments and technologies are used to assess motor function in dyskinetic cerebral palsy, with the majority using 3D motion capture and surface electromyography. Only for a small number of instruments methodological quality was assessed, with only one study showing an adequate assessment of test-retest reliability. The majority of studies was at ICF-CY function and structure level and assessed control of voluntary movement (29 of 49) mainly in the upper extremity, followed by assessment of involuntary movements (15 of 49), muscle tone/motor reflex (6 of 49), gait pattern (5 of 49) and muscle power (2 of 49). At ICF-CY level of activities and participation hand and arm use (9 of 49), fine hand use (5 of 49), lifting and carrying objects (3 of 49), maintaining a body position (2 of 49), walking (1 of 49) and moving around using equipment (1 of 49) was assessed. Only a few methods are potentially suitable outside the clinical environment (e.g. inertial sensors, accelerometers). CONCLUSION Although the current review shows the potential of several instrumented methods to be used as objective outcome measures in dyskinetic cerebral palsy, their methodological quality is still unknown. Future development should focus on evaluating clinimetrics, including validating against clinical meaningfulness. New technological developments should aim for measurements that can be applied outside the laboratory.
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Affiliation(s)
- Helga Haberfehlner
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, PO Box 7057, Amsterdam, 1007MB, The Netherlands.
| | - Marije Goudriaan
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, PO Box 7057, Amsterdam, 1007MB, The Netherlands
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Laura A Bonouvrié
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, PO Box 7057, Amsterdam, 1007MB, The Netherlands
| | - Elise P Jansma
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Jaap Harlaar
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, PO Box 7057, Amsterdam, 1007MB, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - R Jeroen Vermeulen
- Department of Neurology, Section of Pediatric Neurology, Maastricht UMC+, Maastricht, The Netherlands
| | - Marjolein M van der Krogt
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, PO Box 7057, Amsterdam, 1007MB, The Netherlands
| | - Annemieke I Buizer
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, PO Box 7057, Amsterdam, 1007MB, The Netherlands
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Bertucco M, Sanger TD. A Model to Estimate the Optimal Layout for Assistive Communication Touchscreen Devices in Children With Dyskinetic Cerebral Palsy. IEEE Trans Neural Syst Rehabil Eng 2019; 26:1371-1380. [PMID: 29985146 DOI: 10.1109/tnsre.2018.2840445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Excess involuntary movements and slowness of movement in children with dyskinetic cerebral palsy often result in the inability to properly interact with augmentative and alternative communication (AAC) devices. This significantly limits communication. It is, therefore, essential to know how to adjust the device layout in order to maximize each child's rate of communication. The aim of this paper was to develop a mathematical model to estimate the information rate in children with dyskinetic cerebral palsy and to determine the optimal AAC layout for a touchscreen tablet that results in enhanced speed of communication. The model predicts information rate based on button size, number, spacing between buttons, and the probability of making an error or missing target buttons. Estimation of the information rate confirmed our hypothesis of lower channel capacity in children with dyskinetic cerebral palsy compared with age-matched healthy children. Information rate increased when the AAC layout was customized based on the optimal parameters predicted by the model. In conclusion, this paper quantifies the effect of motor impairments on communication with assistive communication devices and shows that communication performance can be improved by optimally matching the parameters of the AAC touchscreen device to the abilities of the child.
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Sanger TD. Basic and Translational Neuroscience of Childhood-Onset Dystonia: A Control-Theory Perspective. Annu Rev Neurosci 2018; 41:41-59. [PMID: 29490197 DOI: 10.1146/annurev-neuro-080317-061504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Dystonia is a collection of symptoms with involuntary muscle activation causing hypertonia, hyperkinetic movements, and overflow. In children, dystonia can have numerous etiologies with varying neuroanatomic distribution. The semiology of dystonia can be explained by gain-of-function failure of a feedback controller that is responsible for stabilizing posture and movement. Because postural control is maintained by a widely distributed network, many different anatomic regions may be responsible for symptoms of dystonia, although all features of dystonia can be explained by uncontrolled activation or hypersensitivity of motor cortical regions that can cause increased reflex gain, inserted postures, or sensitivity to irrelevant sensory variables. Effective treatment of dystonia in children requires an understanding of the relationship between etiology, anatomy, and the specific mechanism of failure of postural stabilization.
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Affiliation(s)
- Terence D Sanger
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California 90089, USA;
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Ellis MD, Schut I, Dewald JPA. Flexion synergy overshadows flexor spasticity during reaching in chronic moderate to severe hemiparetic stroke. Clin Neurophysiol 2017; 128:1308-1314. [PMID: 28558314 DOI: 10.1016/j.clinph.2017.04.028] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/10/2017] [Accepted: 04/30/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Pharmaceutical intervention targets arm flexor spasticity with an often-unsuccessful goal of improving function. Flexion synergy is a related motor impairment that may be inadvertently neglected. Here, flexor spasticity and flexion synergy are disentangled to determine their contributions to reaching dysfunction. METHODS Twenty-six individuals participated. A robotic device systematically modulated shoulder abduction loading during ballistic reaching. Elbow muscle electromyography data were partitioned into windows delineated by elbow joint velocity allowing for the separation of synergy- and spasticity-related activation. RESULTS Reaching velocity decreased with abduction loading (p<0.001) such that velocity was 30% slower when lifting the arm at 50% of abduction strength compared to when arm weight was supported. Abnormal flexion synergy increased with abduction loading (p<0.001) such that normalized activation ranged from a median (interquartile range) of 0.07 (0.03-0.12) when arm weight was supported to 0.19 (0.12-0.40) when actively lifting (large effect size, d=0.59). Flexor spasticity was detected during reaching (p=0.016) but only when arm weight was supported (intermediate effect size, d=0.33). CONCLUSION Flexion synergy is the predominant contributor to reaching dysfunction while flexor spasticity appears only relevant during unnaturally occurring passively supported movement. SIGNIFICANCE Interventions targeting flexion synergy should be leveraged in future stroke recovery trials.
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Affiliation(s)
- Michael D Ellis
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Ingrid Schut
- Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Julius P A Dewald
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Faculty of Science and Technology, University of Twente, Enschede, Netherlands
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The International Classification of Functioning (ICF) to evaluate deep brain stimulation neuromodulation in childhood dystonia-hyperkinesia informs future clinical & research priorities in a multidisciplinary model of care. Eur J Paediatr Neurol 2017; 21:147-167. [PMID: 27707656 DOI: 10.1016/j.ejpn.2016.08.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/11/2016] [Accepted: 08/29/2016] [Indexed: 12/12/2022]
Abstract
The multidisciplinary team (MDT) approach illustrates how motor classification systems, assessments and outcome measures currently available have been applied to a national cohort of children and young people with dystonia and other hyperkinetic movement disorders (HMD) particularly with a focus on dyskinetic cerebral palsy (CP). The paper is divided in 3 sections. Firstly, we describe the service model adopted by the Complex Motor Disorders Service (CMDS) at Evelina London Children's Hospital and King's College Hospital (ELCH-KCH) for deep brain stimulation. We describe lessons learnt from available dystonia studies and discuss/propose ways to measure DBS and other dystonia-related intervention outcomes. We aim to report on current available functional outcome measures as well as some impairment-based assessments that can encourage and generate discussion among movement disorders specialists of different backgrounds regarding choice of the most important areas to be measured after DBS and other interventions for dystonia management. Finally, some recommendations for multi-centre collaboration in regards to functional clinical outcomes and research methodologies for dystonia-related interventions are proposed.
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Kukke SN, Curatalo LA, de Campos AC, Hallett M, Alter KE, Damiano DL. Coordination of Reach-to-Grasp Kinematics in Individuals With Childhood-Onset Dystonia Due to Hemiplegic Cerebral Palsy. IEEE Trans Neural Syst Rehabil Eng 2015. [PMID: 26208359 DOI: 10.1109/tnsre.2015.2458293] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Functional reaching is impaired in dystonia. Here, we analyze upper extremity kinematics to quantify timing and coordination abnormalities during unimanual reach-to-grasp movements in individuals with childhood-onset unilateral wrist dystonia. Kinematics were measured during movements of both upper limbs in a patient group ( n = 11, age = 17.5 ±5 years), and a typically developing control group ( n = 9, age = 16.6 ±5 years). Hand aperture was computed to study the coordination of reach and grasp. Time-varying joint synergies within one upper limb were calculated using a novel technique based on principal component analysis to study intra-limb coordination. In the non-dominant arm, results indicate reduced coordination between reach and grasp in patients who could not lift the grasped object compared to those who could lift it. Lifters exhibit incoordination in distal upper extremity joints later in the movement and non-lifters lacked coordination throughout the movement and in the whole upper limb. The amount of atypical coordination correlates with dystonia severity in patients. Reduced coordination during movement may reflect deficits in the execution of simultaneous movements, motor planning, or muscle activation. Rehabilitation efforts can focus on particular time points when kinematic patterns deviate abnormally to improve functional reaching in individuals with childhood-onset dystonia.
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Sohn WJ, Niu CM, Sanger TD. Increased long-latency reflex activity as a sufficient explanation for childhood hypertonic dystonia: a neuromorphic emulation study. J Neural Eng 2015; 12:036010. [PMID: 25946372 PMCID: PMC4475677 DOI: 10.1088/1741-2560/12/3/036010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Childhood dystonia is a movement disorder that interferes with daily movements and can have a devastating effect on quality of life for children and their families. Although injury to basal ganglia is associated with dystonia, the neurophysiological mechanisms leading to the clinical manifestations of dystonia are not understood. Previous work suggested that long-latency stretch reflex (LLSR) is hyperactive in children with hypertonia due to secondary dystonia. We hypothesize that abnormal activity in motor cortices may cause an increase in the LLSR leading to hypertonia. APPROACH We modeled two possibilities of hyperactive LLSR by either creating a tonic involuntary drive to cortex, or increasing the synaptic gain in cortical neurons. Both models are emulated using programmable very-large-scale-integrated-circuit hardware to test their sufficiency for producing dystonic symptoms. The emulation includes a joint with two Hill-type muscles, realistic muscle spindles, and 2,304 Izhikevich-type spiking neurons. The muscles are regulated by a monosynaptic spinal pathway with 32 ms delay and a long-latency pathway with 64 ms loop-delay representing transcortical/supra-spinal connections. MAIN RESULTS When the limb is passively stretched, both models produce involuntary resistance with increased antagonist EMG responses similar to human data; also the muscle relaxation is delayed similar to human data. Both models predict reduced range of motion in voluntary movements. SIGNIFICANCE Although our model is a highly simplified and limited representation of reflex pathways, it shows that increased activity of the LLSR is by itself sufficient to cause many of the features of hypertonic dystonia.
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Affiliation(s)
- Won J. Sohn
- Department of Biomedical Engineering, University of Southern California, 1042 Downey Way, Los Angeles, California, 90089
| | - Chuanxin M. Niu
- Department of Rehabilitation, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Terence D. Sanger
- Department of Biomedical Engineering, University of Southern California, 1042 Downey Way, Los Angeles, California, 90089
- Department of Biokinesiology, University of Southern California, 1042 Downey Way, Los Angeles, California, 90089
- Department of Neurology, University of Southern California, 1042 Downey Way, Los Angeles, California, 90089
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de Campos AC, Kukke SN, Hallett M, Alter KE, Damiano DL. Characteristics of bilateral hand function in individuals with unilateral dystonia due to perinatal stroke: sensory and motor aspects. J Child Neurol 2014; 29:623-32. [PMID: 24396131 PMCID: PMC4096971 DOI: 10.1177/0883073813512523] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The authors assessed bilateral motor and sensory function in individuals with upper limb dystonia due to unilateral perinatal stroke and explored interrelationships of motor function and sensory ability. Reach kinematics and tactile sensation were measured in 7 participants with dystonia and 9 healthy volunteers. The dystonia group had poorer motor (hold time, reach time, shoulder/elbow correlation) and sensory (spatial discrimination, stereognosis) outcomes than the control group on the nondominant side. On the dominant side, only sensation (spatial discrimination, stereognosis) was poorer in the dystonia group compared with the control group. In the dystonia group, although sensory and motor outcomes were uncorrelated, dystonia severity was related to poorer stereognosis, longer hold and reach times, and decreased shoulder/elbow coordination. Findings of bilateral sensory deficits in dystonia can be explained by neural reorganization. Visual compensation for somatosensory changes in the nonstroke hemisphere may explain the lack of bilateral impairments in reaching.
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Affiliation(s)
| | - Sahana N. Kukke
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center,Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health
| | - Katharine E. Alter
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center,Mount Washington Pediatric Hospital
| | - Diane L. Damiano
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center
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