Keeping your head on target

Pallidal multifractal complexity is a new potential physiomarker of dystonia

OBJECTIVE

Low-frequency 4-12 Hz pallidal oscillations are being considered as potential physiomarkers for dystonia. We suggest investigating the multifractal properties of pallidal activity as an additional marker.

METHODS

We employed local field potentials (LFP) recordings from 23 patients with dystonia who were undergoing deep brain stimulation (DBS) surgery to explore the connection between disease severity and the multifractal characteristics of pallidal activity. Furthermore, we performed an analysis of LFP recordings from four patients, following the externalization of DBS lead electrodes, to investigate the impact of DBS and neck muscle vibration on multifractal parameters.

RESULTS

Greater dystonia severity exhibited a correlation with a narrower multifractal spectrum width but higher multifractal spectral asymmetry. Both GPi DBS and muscle vibration in dystonia patients expanded the multifractal spectrum width while restoring multifractal spectral symmetry. Notably, the threshold peak intensities for an increase in multifractal spectrum width substantially overlapped with the optimal volume of tissue activated. A broader multifractal spectrum during DBS corresponded to more favorable clinical outcomes.

CONCLUSIONS

Multifractal properties of pallidal neuronal activity serve as indicators of neural dysfunction in dystonia.

SIGNIFICANCE

These findings suggest the potential of utilizing multifractal characteristics as predictive factors for the DBS outcome in dystonia.

Interdisciplinary insights into tremor in dystonia: Navigating clinical controversies, definitional challenges, and pathophysiological complexities

This review delves into the historical evolution and ongoing controversy surrounding the relationship between tremor and dystonia. The Dystonia Consensus Panel and the International Parkinson's and Movement Disorders Society's Tremor Taskforce have attempted to define these entities, but the complexity arises when patients have a combination of both dystonia and tremor. The term "dystonic tremor" has sparked diverse interpretations, with debates over its clinical features and the need for more objectively defined characteristics. Logistic regression analyses in a large cohort of dystonia patients identified determinants such as body region affected by dystonia, dystonia severity, age, and recruitment site, with unexpected associations emphasizing the subjectivity in detecting and classifying tremor. The study further discovered diverse prevalence of "dystonic tremor" based on different definitions, revealing substantial variability among investigators. The recently convened Dystonia-Tremor panel aimed to address these challenges by proposing a more uniform nomenclature, emphasizing precise and descriptive terms. Despite the complexity, instrumented measures, such as electromyography, temporal discrimination threshold, blink reflex, and trajectory shape analysis, seem to be useful in distinguishing between tremor and dystonia. The pathophysiology debate centers around the involvement of the cerebello-thalamo-cortical and basal ganglia-thalamo-cortical circuits. Evidence supports the role of both circuits in driving the pathophysiology of dystonic tremor, challenging the notion of a clear dichotomy. The review concludes by emphasizing the need for a nuanced understanding, highlighting the intricate interplay between tremor and dystonia, and the potential of instrumental measures in advancing diagnostic accuracy.

Proprioceptive Modulation of Pallidal Physiology in Cervical Dystonia

BACKGROUND

There is a growing body of evidence suggesting that botulinum toxin can alter proprioceptive feedback and modulate the muscle-spindle output for the treatment of dystonia. However, the mechanism for this modulation remains unclear.

METHODS

We conducted a study involving 17 patients with cervical dystonia (CD), seven of whom had prominent CD and 10 with generalized dystonia (GD) along with CD. We investigated the effects of neck vibration, a form of proprioceptive modulation, on spontaneous single-neuron responses and local field potentials (LFPs) recorded from the globus pallidum externus (GPe) and internus (GPi).

RESULTS

Our findings demonstrated that neck vibration notably increased the regularity of neck-sensitive GPi neurons in focal CD patients. Additionally, in patients with GD and CD, the vibration enhanced the firing regularity of non-neck-sensitive neurons. These effects on single-unit activity were also mirrored in ensemble responses measured through LFPs. Notably, the LFP modulation was particularly pronounced in areas populated with burst neurons compared to pause or tonic cells.

CONCLUSION

The results from our study emphasize the significance of burst neurons in the pathogenesis of dystonia and in the efficacy of proprioceptive modulation for its treatment. Moreover, we observed that the effects of vibration on focal CD were prominent in the α band LFP, indicating modulation of pallido-cerebellar connectivity. Moreover, the pallidal effects of vibration in GD with CD involved modulation of cerebro-pallidal θ band connectivity. Our analysis provides insight into how vibration-induced changes in pallidal activity are integrated into the downstream motor circuit. © 2023 International Parkinson and Movement Disorder Society.

Isolated Cervical Dystonia: Diagnosis and Classification

This document presents a consensus on the diagnosis and classification of isolated cervical dystonia (iCD) with a review of proposed terminology. The International Parkinson and Movement Disorder Society Dystonia Study Group convened a panel of experts to review the main clinical and diagnostic issues related to iCD and to arrive at a consensus on diagnostic criteria and classification. These criteria are intended for use in clinical research, but also may be used to guide clinical practice. The benchmark is expert clinical observation and evaluation. The criteria aim to systematize the use of terminology as well as the diagnostic process, to make it reproducible across centers and applicable by expert and non-expert clinicians. Although motor abnormalities remain central, increasing recognition has been given to nonmotor manifestations, which are incorporated into the current criteria. Three iCD presentations are described in some detail: idiopathic (focal or segmental) iCD, genetic iCD, and acquired iCD. The relationship between iCD and isolated head tremor is also reviewed. Recognition of idiopathic iCD has two levels of certainty, definite or probable, supported by specific diagnostic criteria. Although a probable diagnosis is appropriate for clinical practice, a higher diagnostic level may be required for specific research studies. The consensus retains elements proven valuable in previous criteria and omits aspects that are no longer justified, thereby encapsulating diagnosis according to current knowledge. As understanding of iCD expands, these criteria will need continuous revision to accommodate new advances. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Impaired trunk control and its relationship with balance, functional mobility, and disease severity in patients with cervical dystonia

BACKGROUND

Impaired trunk control is common in neurological disorders; however, trunk control has not been examined in patients with cervical dystonia (CD). Therefore, the primary aim was to compare trunk control between patients with CD and healthy people. The secondary aim was to investigate the relationship between trunk control and balance, functional mobility, and disease severity in patients with CD.

METHODS

]This cross-sectional study included 32 patients with CD and 32 healthy people. Trunk control was compared using the trunk impairment scale (TIS) that consists of three subscales: static sitting balance, dynamic sitting balance, and trunk coordination between two groups. Balance was assessed using Berg Balance Scale, four square step test, and one-leg stance test. The Timed Up and Go Test was measured to determine functional mobility. Toronto Western Spasmodic Torticollis Rating Scale was used to evaluate disease severity.]></AbstractText> <AbstractText Label="RESULTS"><![CDATA[ Patients with CD demonstrated worse performance on the TIS-total with TIS-dynamic sitting subscale and TIS-trunk coordination subscale (p < 0.001, p < 0.001, and p < 0.001), except for TIS-static sitting subscale (p = 0.078) compared to healthy people. TIS-total scores had moderate to strong correlations with balance, functional mobility, and disease severity (range r between 0.786 and 0.536, p < 0.05 for all). There was no correlation between TIS-total scores and disease severity (p = 0.102).

DISCUSSION

Patients with CD had impaired trunk control, especially in dynamic sitting balance and trunk coordination. Impaired trunk control was also associated with balance and functional mobility but not disease severity. These findings suggest that trunk control deficits should receive attention in the assessment and treatment of patients with CD.

Clinical features, pathophysiology, treatment, and controversies of tremor in dystonia

Dystonia and tremor frequently co-occur. In some cases, they have shared biological mechanisms, while in others dystonia and tremor are two comorbid conditions. The term "dystonic tremor" is used to describe tremor in those who have dystonia. Two mutually exclusive definitions of "dystonic tremor" were proposed. According to one definition, dystonic tremor is the tremor in the dystonic body part. An alternate definition of dystonic tremor entails irregular and jerky oscillations that have saw tooth appearance with or without overt dystonia. This paper outlines the differences in two definitions of dystonic tremor and identifies their limitations. Given the diverse views defining "dystonic tremor", this paper will use the term "tremor in dystonia". In addition, we will outline different ways to separate the subtypes of tremor in dystonia. Then we will discuss pathophysiological mechanisms derived from the objective measures and single neuron physiology analyses of tremor in dystonia. This article is part of the Special Issue "Tremor" edited by Daniel D. Truong, Mark Hallett, and Aasef Shaikh.

From null to midline: changes in head posture do not predictably change head tremor in cervical dystonia

Introduction

A common view is that head tremor (HT) in cervical dystonia (CD) decreases when the head assumes an unopposed dystonic posture and increases when the head is held at midline. However, this has not been examined with objective measures in a large, multicenter cohort.

Methods

For 80 participants with CD and HT, we analyzed videos from examination segments in which participants were instructed to 1) let their head drift to its most comfortable position (null point) and then 2) hold their head straight at midline. We used our previously developed Computational Motor Objective Rater (CMOR) to quantify changes in severity, amplitude, and frequency between the two postures.

Results

Although up to 9% of participants had exacerbated HT in midline, across the whole cohort, paired t-tests reveal no significant changes in overall severity (t = -0.23, p = 0.81), amplitude (t = -0.80, p = 0.43), and frequency (t = 1.48, p = 0.14) between the two postures.

Conclusions

When instructed to first let their head drift to its null point and then to hold their head straight at midline, most patient's changes in HT were below the thresholds one would expect from the sensitivity of clinical rating scales. Counter to common clinical impression, CMOR objectively showed that HT does not consistently increase at midline posture in comparison to the null posture.

"Leaky" and "Unstable" Neural Integrator Can Coexist-Paradox Observed in Multiple Sclerosis

The mechanism for stable gaze-holding requires a neural integrator that converts pulse of neural discharge to steady firing rate. The integrator is feedback-dependent, impaired feedback manifests as either "unstable" integration when it is too much or "leaky" when it is too little. The "unstable" integrator is known to cause sinusoidal oscillations of the eyes called pendular nystagmus, whereas the "leaky" integrator causes jerky eye oscillations called gaze-evoked nystagmus. We hypothesized that integrator can be simultaneously leaky and unstable. Mechanistically, some parts of network are served by increased feedback gain (unstable network), while other part would be decreased feedback gain (leaky). Both leaky and unstable, the network converges on the ocular motor plant, leading to simultaneously present gaze-evoked jerk and sinusoidal nystagmus. We tested our hypothesis by measuring eye movements with search coil technique in 7 multiple sclerosis patients. Five of these patients had gaze-evoked nystagmus and superimposed pendular nystagmus. The gaze-evoked nystagmus depicted all the features of "leaky" integrator, that is, the drifts were always toward the null that was located at the central eye-in-orbit orientation, there were no drifts at null, and the drift velocity increased as the eyes moved farther away from the null. The pendular nystagmus had all the features of "unstable" integrator, that is, constant 4- to 6-Hz frequency, eye-in-orbit position dependence of the oscillation amplitude, and the voluntary saccade causing an oscillatory phase reset. These features were then simulated in a computational model conceptualizing our hypothesis of simultaneously leaky and unstable neural integrator.

Pallidal Activity in Cervical Dystonia with and Without Head Tremor

The relationship between two common movement disorders, dystonia and tremor, is controversial. Both deficits have correlates in the network that includes connections between the cerebellum and the basal ganglia. In order to assess the physiological relationship between tremor and dystonia, we measured the activity of 727 pallidal single-neurons during deep brain stimulation surgery in patients with cervical dystonia without head oscillations, cervical dystonia plus jerky oscillations, and cervical dystonia with sinusoidal oscillations. Cluster analyses of spike-train recordings allowed classification of the pallidal activity into burst, pause, and tonic. Burst neurons were more common, and number of spikes within spike and inter-burst intervals was shorter in pure dystonia and jerky oscillation groups compared to the sinusoidal oscillation group. Pause neurons were more common and irregular in pure tremor group compared to pure dystonia and jerky oscillation groups. There was bihemispheric asymmetry in spontaneous firing discharge in pure dystonia and jerky oscillation groups, but not in sinusoidal oscillation group. These results demonstrate that the physiology of pallidal neurons in patients with pure cervical dystonia is similar to those who have cervical dystonia combined with jerky oscillations, but different from those who have cervical dystonia combined with sinusoidal oscillations. These results imply distinct mechanistic underpinnings for different types of head oscillations in cervical dystonia.

Dystonia and Tremor: A Cross-Sectional Study of the Dystonia Coalition Cohort

OBJECTIVE

To assess the clinical manifestations and predictors of different types of tremors in individuals with different types of isolated dystonia.

METHODS

Clinical manifestations of tremor were assessed in a multicenter, international cross-sectional, cohort study of 2,362 individuals with all types of isolated dystonia (focal, segmental, multifocal, and generalized) recruited through the Dystonia Coalition.

RESULTS

Methodical and standardized assessments of all participants in this cohort revealed the overall prevalence of any type of tremor was 53.3%. The prevalence of dystonic tremor varied from 36.9% to 48.4%, depending on criteria used to define it. To identify the factors associated with tremors in dystonia, the data were analyzed by generalized linear modeling and cluster analyses. Generalized linear modeling indicated 2 of the strongest factors associated with tremor included body region affected by dystonia and recruitment center. Tremor was also associated with severity of dystonia and duration of dystonia, but not with sex or race. The cluster analysis distinguished 8 subgroups within the whole cohort; defined largely by body region with dystonia, and secondarily by other clinical characteristics.

CONCLUSION

The large number of cases evaluated by an international team of movement disorder experts facilitated the dissection of several important factors that influence the apparent prevalence and phenomenology of tremor in dystonia. These results are valuable for understanding the many differences reported in prior studies, and for guiding future studies of the nosology of tremor and dystonia.

Neuronal Activity of Pallidal Versus Cerebellar Receiving Thalamus in Patients with Cervical Dystonia

Cervical dystonia (CD) is a movement disorder characterized by a stereotyped pattern of involuntary turning or tilting of the head, often combined with jerky or tremulous movements. Hypotheses for the origin of CD have traditionally focused on the basal ganglia, but the contemporary discussion has considered the potential role of altered cerebellar function. As basal ganglia and the cerebellum largely project to the different thalamic nuclei, alterations in pallidal versus cerebellar output could be reflected in the activity of these thalamic regions. In this study, we analyzed a unique historic database where the single-unit activity of pallidal and cerebellar receiving thalamic nuclei was measured en route to the mesencephalon. We compared the single-unit activity of pallidal and cerebellar receiving thalamic neurons in three groups of CD patients manifesting as pure dystonia, pure jerky head oscillations, and dystonia plus jerky head oscillations. We found that among different CD manifestations, the characteristics of neuronal firing, such as burst versus a single-spike pattern, vary in cerebellar thalamic receiving nuclei. The cerebellar receiving region in patients with jerky oscillations had single-spikes neurons primarily. Wherein the manifestation of CD did not influence pattern distribution in the pallidal receiving thalamic area. We also found increased neuronal firing rate correlated with strength of theta-band neuronal oscillations during muscle contractions associated with dystonia. These results demonstrate that the manifestations of CD, such as pure dystonia, pure jerky head oscillations, or dystonia and jerky head oscillations, determine the thalamic neuronal properties.

Feedback-dependent neuronal properties make focal dystonias so focal

Focal dystonia, by definition, affects a specific body part; however, it may have a widespread neural substrate. We tested this hypothesis by examining the intrinsic behaviour and the neuronal properties that are modulated by changes in the physiological behaviour of their connections, that is feedback dependence, of the isolated pallidal neurons. During deep brain stimulation surgery in 12 patients with isolated cervical dystonia (without hand involvement), we measured spontaneous as well as evoked single-unit properties in response to fist making (hand movement) or shoulder shrug (neck movements). We measured the activity of isolated neurons that were only sensitive to the neck movements, hand movement, or not responsive to hand or neck movements. The spontaneous firing behaviour, such as the instantaneous firing rate and its regularity, was comparable in all three types of neurons. The neck movement-sensitive neurons had prominent bursting behaviour in comparison with the hand neurons. The feedback dependence of the neck movement-sensitive neurons was also significantly impaired when compared to hand movement-sensitive neurons. Motor-evoked change in firing rate of neck movement-sensitive neurons rapidly declined; the decay time constant was much shorter compared to hand movement-sensitive neurons. These results suggest that in isolated cervical dystonia, at the resolution of single neurons, the deficits are much widespread, affecting the neurons that drive the neck movement as well as the hand movements. We speculate that clinically discernable dystonia occurs when additional abnormality is added to baseline dysfunctional network, and one source of such abnormality may involve feedback.

Lessons learned from the syndrome of oculopalatal tremor

The syndrome of oculopalatal tremor (OPT) featuring the olivo-cerebellar hypersychrony leads to disabling pendular nystagmus and palatal myoclonus. This rare disorder provides valuable information about the motor physiology and offers insights into the mechanistic underpinning of common movement disorders. This focused review summarizes the last decade of OPT research from our laboratory and addresses three critical questions: 1) How the disease of inferior olive affects the physiology of motor learning? We discovered that our brain's ability to compensate for the impaired motor command and implement errors to correct future movements could be affected if the cerebellum is occupied in receiving and transmitting the meaningless signal. A complete failure of OPT patients to adapt to change in rapid eye movements (saccades) provided proof of this principle. 2) Whether maladaptive olivo-cerebellar circuit offers insight into the mechanistic underpinning of the common movement disorder, dystonia, characterized by abnormal twisting and turning of the body part. We discovered that the subgroup of patients who had OPT also had dystonia affecting the neck, trunk, limbs, and face. We also found that the subjects who had tremor predominant neck dystonia (without OPT) also had impaired motor learning on a long and short timescale, just like those with OPT. Altogether, our studies focused on dystonia suggested the evidence for the maladaptive olive-cerebellar system. 3) We discovered that the OPT subjects had difficulty in perceiving the direction of their linear forward motion, i.e., heading, suggesting that olivo-cerebellar hypersynchrony also affects perception.

Pallidal 1/f asymmetry in patients with cervical dystonia

Lateralized differences in pallidal outflow are putatively linked to asymmetric tonic contractions of the neck muscles in cervical dystonia (CD). At the population level, the interhemispheric asymmetry has been traditionally studied for the estimation of the spectral power in specified frequency bands. Broadband spectral features, however, were not taken into consideration. The contemporary analysis revealed that the aperiodic (1/f) broadband activity could be a neurophysiological marker of the excitation/inhibition ratio. During deep brain stimulation (DBS) surgery, we measured bilateral pallidal local field potentials (LFP) in nine CD patients, examining the effects of lateralized asymmetry on 1/f broadband activity. All patients showed a trend towards an asymmetric difference in the 1/f broadband activity. The ipsilateral 1/f slope was significantly higher in internal (GPi) segment of the globus pallidus that is on the contralateral side of the direction of the dystonia. We also found lateralized differences in the beta oscillations for GPi and in the alpha oscillations for GPe. Our findings emphasize the importance of mainstreaming broadband activity in the estimation of LFP spectral features together with periodic features and provide further evidence for the pallidal asymmetry in CD patients.

Oculomotor functions in focal dystonias: A systematic review

Focal Dystonia (FD) is a chronic neurological disorder, which causes twisting and repetitive movements and abnormal postures induced by involuntary sustained contractions of agonist and antagonist muscles. Based on the hypothesis that several dystonia-related brain regions, including cerebellum, are implicated in oculomotor disturbances (OCD), a number of studies investigated oculomotor function in patients with dystonia. However, conceptual clarity with respect to the used assessment tools and interpretation of the findings is lacking in the literature. This is the first article to systematically review studies that assessed oculomotor function in patients with FD. In total, 329 publications, published until September 1, 2019, were identified through MEDLINE search. Twenty out of 329 studies, involving 232 subjects in total, met the inclusion criteria. Most of the studies reported oculomotor disturbances in patients with FD. Abnormalities included asymmetry in vestibulo-ocular reflex (VOR), disturbances in saccadic functions, and prolonged latencies of eye motion. Discrepancies in the results could be explained, at least partially, by the long period of time over which the reviewed studies were published, the different methods used for testing the eye movements, and the limited number of patients assessed since the majority of data derived from case reports or small-scale studies. Further prospective studies with larger subject numbers are needed, using advanced tools for the assessment of oculomotor function in focal dystonia.

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.

Soft Material-Enabled, Active Wireless, Thin-Film Bioelectronics for Quantitative Diagnostics of Cervical Dystonia

Recent advances in flexible materials, nanomanufacturing, and system integration have provided a great opportunity to develop wearable flexible hybrid electronics for human healthcare, diagnostics, and therapeutics. However, existing medical devices still rely on rigid electronics with many wires and separate components, which hinders wireless, comfortable, continuous monitoring of health-related human motions. Here, we introduce advanced materials and system integration technologies that enable a soft, active wireless, thin-film bioelectronics. The low-modulus, highly flexible wearable electronic system incorporates a nanomembrane wireless circuit and functional chip components, enclosed by a soft elastomeric membrane. The bioelectronic system offers a gentle, seamless mounting on the skin, while offering a comfortable, highly sensitive and accurate detection of head movements. We utilize the wireless wearable hybrid system for quantitative diagnostics of cervical dystonia (CD) that is characterized by involuntary abnormal head postures and repetitive head movements, sometimes with neck muscle pain. A set of analytical and experimental studies shows a soft system packaging, hard-soft materials integration, and quantitative assessment of physiological signals detected by the SKINTRONICS. In vivo demonstration, involving ten human subjects, captures the device feasibility for use in CD measurement.

Relationship between jerky and sinusoidal oscillations in cervical dystonia

INTRODUCTION

Dystonia is often associated with repetitive jerky oscillations (i.e. dystonic tremor), while tremor is characterized by sinusoidal oscillations. We propose two competing predictions for dystonic tremor and sinusoidal tremor relationship. In any given patient, (1) the oscillation could be characterized as either sinusoidal or jerky based on the degree of distortion in the waveforms, (2) the oscillation consists of both sinusoidal and jerky waveforms mixed in a certain proportion that varies among individuals. We objectively test these predictions in patients with cervical dystonia.

METHODS

We recorded head oscillations in 14 subjects with cervical dystonia using a high-resolution magnetic field search coil system. Distortion in the signal was used as a measure of jerkiness. A hierarchical clustering classified the oscillations based on distortion characteristics.

RESULTS

Signal analysis in the frequency domain allowed identification of the components of the waveforms at frequencies other than the fundamental frequency. The distortion from the component at fundamental frequency was present in both low and high frequency range. Based on varying levels of distortions, i.e. jerkiness, the head oscillations were grouped into 4 clusters: one cluster with lowest distortion (sinusoidal waveforms), one cluster with highest distortion (jerky waveforms), and two intermediate clusters - one with distortion at low frequency and another with distortion at high frequency. The distribution of 4 clusters varied across subjects suggesting co-existence of sinusoidal and jerky waveforms.

CONCLUSION

These results support the prediction that jerky and sinusoidal waveforms concur in cervical dystonia. Amount of concurrence varies amongst patients.

Tremor in chronic inflammatory demyelinating polyneuropathy: Proof of unifying network model for dystonia

Traditional hypotheses for the pathogenesis of dystonia, the third most common movement disorder, have focused primarily on the basal ganglia. Contemporary theories have emphasized the role of the cerebellum. The modulation of peripheral proprioception also affects dystonia. We proposed a unifying network model for dystonia where the cerebellum, basal ganglia, and peripheral proprioception are connected in a circuit that forms the neural integrator network, ensuring steady position. We suggested that impairment anywhere along this circuit leads to common phenomenology-slow drifts followed by corrective movements, resembling dystonic tremor. We tested this concept in a patient with chronic inflammatory demyelinating polyneuropathy with resulting abnormal proprioception. Quantitative assessment of tremor in this patient revealed drifts in limb position followed by corrective movements and superimposed sinusoidal oscillations-consistent with neural integrator dysfunction. This unique case of chronic inflammatory demyelinating polyneuropathy describes the role of proprioception on the unifying network model for dystonia.

The role of pallidum in the neural integrator model of cervical dystonia

Dystonia is the third most common movement disorder affecting three million people worldwide. Cervical dystonia is the most common form of dystonia. Despite common prevalence the pathophysiology of cervical dystonia is unclear. Traditional view is that basal ganglia is involved in pathophysiology of cervical dystonia, while contemporary theories suggested the role of cerebellum and proprioception in the pathophysiology of cervical dystonia. It was recently proposed that the cervical dystonia is due to malfunctioning of the head neural integrator - the neuron network that normally converts head velocity to position. Most importantly the neural integrator model was inclusive of traditional proposal emphasizing the role of basal ganglia while also accommodating the contemporary view suggesting the involvement of cerebellum and proprioception. It was hypothesized that the head neural integrator malfunction is the result of impairment in cerebellar, basal ganglia, or proprioceptive feedback that converge onto the integrator. The concept of converging input from the basal ganglia, cerebellum, and proprioception to the network participating in head neural integrator explains that abnormality originating anywhere in the network can lead to the identical motor deficits - drifts followed by rapid corrective movements - a signature of neural integrator dysfunction. We tested this hypothesis in an experiment examining simultaneously recorded globus pallidal single-unit activity, synchronized neural activity (local field potential), and electromyography (EMG) measured from the neck muscles during the standard-of-care deep brain stimulation surgery in 12 cervical dystonia patients (24 hemispheres). Physiological data were collected spontaneously or during voluntary shoulder shrug activating the contralateral trapezius muscle. The activity of pallidal neurons during shoulder shrug exponentially decayed with time constants that were comparable to one measured from the pretectal neural integrator and the trapezius electromyography. These results show that evidence of abnormal neural integration is also seen in globus pallidum, and that latter is connected with the neural integrator. Pretectal single neuron responses consistently preceded the muscle activity; while the globus pallidum internus response always lagged behind the muscle activity. Globus pallidum externa had equal proportion of lag and lead neurons. These results suggest globus pallidum receive feedback from the muscles or the efference copy from the integrator or the other source of the feedback. There was bi-hemispheric asymmetry in the pallidal single-unit activity and local field potentials. The asymmetry correlated with degree of lateral head turning in cervical dystonia patients. These results suggest that bihemispheric asymmetry in the feedback leads to asymmetric dysfunction in the neural integrator causing head turning.

Targeting head movements in humans: Compensation for disturbance from simultaneous body rotations

Vestibular information plays an important role in spatially oriented motor control and perception. With regard to reorienting head movements, little is known of (1) how vestibular mechanisms compensate for disturbances from concurrent passive trunk rotations (e.g. in a veering vehicle), and (2) whether and how this disturbance compensation is related to the perception of body orientation in space. We here address these two questions in a single experiment. Six healthy subjects (Ss) seated on a turning chair in darkness performed two tasks. (1) Head pointing: Ss made swift head movements in darkness towards the angular position in space of a previously shown visual target. These movements were disturbed by concurrent rotations of the chair, and hence the trunk, which were driven by scaled down versions of the Ss' own head-on-trunk rotations. Although unaware of the disturbance, Ss adjusted their head movements so as to attenuate its effect on head-in-space (HS) position by about 45%. (2) Visual straight ahead (VSA): Using a light pointer, Ss indicated their VSA before each head-pointing trial and tried to reproduce it after the trial. In all Ss, VSA accounted for the disturbing trunk rotation, although to individually varying degrees. No correlation could be detected between VSA reproduction and motor performance, neither within nor across subjects. A vestibular loss subject who performed the same two tasks made no compensatory movements during head pointing and did not account for the disturbance of his HS position during VSA reproduction. Three concepts of vestibular information processing for head movement control were explored with regard to their compatibility with the head-pointing results: (1) Conventional negative feedback, (2) Interaction with an efference copy, and (3) Interaction with neck proprioceptive information. Theoretical analyses and model simulations indicated that all three concepts can explain the observed disturbance compensation. However, they differ in terms of control stability in the presence of feedback time delays, with (3) being best and (1) worst. The different concepts might correspond to fast simple and slower complex compensation mechanisms, respectively, and possibly complement each other during natural behaviours. VSA reproduction may be based on analogous processing principles, but appears to involve different neural circuitries.

Abnormal cerebellar processing of the neck proprioceptive information drives dysfunctions in cervical dystonia

The cerebellum can influence the responsiveness of the primary motor cortex (M1) to undergo spike timing-dependent plastic changes through a complex mechanism involving multiple relays in the cerebello-thalamo-cortical pathway. Previous TMS studies showed that cerebellar cortex excitation can block the increase in M1 excitability induced by a paired-associative stimulation (PAS), while cerebellar cortex inhibition would enhance it. Since cerebellum is known to be affected in many types of dystonia, this bidirectional modulation was assessed in 22 patients with cervical dystonia and 23 healthy controls. Exactly opposite effects were found in patients: cerebellar inhibition suppressed the effects of PAS, while cerebellar excitation enhanced them. Another experiment comparing healthy subjects maintaining the head straight with subjects maintaining the head turned as the patients found that turning the head is enough to invert the cerebellar modulation of M1 plasticity. A third control experiment in healthy subjects showed that proprioceptive perturbation of the sterno-cleido-mastoid muscle had the same effects as turning the head. We discuss these finding in the light of the recent model of a mesencephalic head integrator. We also suggest that abnormal cerebellar processing of the neck proprioceptive information drives dysfunctions of the integrator in cervical dystonia.

Postural control and the relation with cervical sensorimotor control in patients with idiopathic adult-onset cervical dystonia

Cervical dystonia (CD) is a movement disorder characterized by involuntary muscle contractions leading to an abnormal head posture or movements of the neck. Dysfunctions in somatosensory integration are present and previous data showed enlarged postural sway in stance. Postural control during quiet sitting and the correlation with cervical sensorimotor control were investigated. Postural control during quiet sitting was measured via body sway parameters in 23 patients with CD, regularly receiving botulinum toxin treatment and compared with 36 healthy controls. Amplitude and velocity of displacements of the center of pressure (CoP) were measured by two embedded force plates at 1000 Hz. Three samples of 30 s were recorded with the eyes open and closed. Disease-specific characteristics were obtained in all patients by the Tsui scale, Cervical Dystonia Impact Profile (CDIP-58) and Toronto Western Spasmodic Rating Scale (TWSTRS). Cervical sensorimotor control was assessed with an infrared Vicon system during a head repositioning task. Body sway amplitude and velocity were increased in patients with CD compared to healthy controls. CoP displacements were doubled in patients without head tremor and tripled in patients with a dystonic head tremor. Impairments in cervical sensorimotor control were correlated with larger CoP displacements (r_s ranged from 0.608 to 0.748). Postural control is impaired and correlates with dysfunction in cervical sensorimotor control in patients with CD. Treatment is currently focused on the cervical area. Further research towards the potential value of postural control exercises is recommended.

Ocular stability and set-point adaptation

A fundamental challenge to the brain is how to prevent intrusive movements when quiet is needed. Unwanted limb movements such as tremor impair fine motor control and unwanted eye drifts such as nystagmus impair vision. A stable platform is also necessary to launch accurate movements. Accordingly, nature has designed control systems with agonist (excitation) and antagonist (inhibition) muscle pairs functioning in push-pull, around a steady level of balanced tonic activity, the set-point Sensory information can be organized similarly, as in the vestibulo-ocular reflex, which generates eye movements that compensate for head movements. The semicircular canals, working in coplanar pairs, one in each labyrinth, are reciprocally excited and inhibited as they transduce head rotations. The relative change in activity is relayed to the vestibular nuclei, which operate around a set-point of stable balanced activity. When a pathological imbalance occurs, producing unwanted nystagmus without head movement, an adaptive mechanism restores the proper set-point and eliminates the nystagmus. Here we used 90 min of continuous 7 T magnetic field labyrinthine stimulation (MVS) in normal humans to produce sustained nystagmus simulating vestibular imbalance. We identified multiple time-scale processes towards a new zero set-point showing that MVS is an excellent paradigm to investigate the neurobiology of set-point adaptation.This article is part of the themed issue 'Movement suppression: brain mechanisms for stopping and stillness'.

Cervical sensorimotor control in idiopathic cervical dystonia: A cross-sectional study

OBJECTIVES

Patients with idiopathic adult-onset cervical dystonia (CD) experience an abnormal head posture and involuntary muscle contractions. Although the exact areas affected in the central nervous system remain uncertain, impaired functions in systems stabilizing the head and neck are apparent such as the somatosensory and sensorimotor integration systems. The aim of the study is to investigate cervical sensorimotor control dysfunction in patients with CD.

MATERIAL AND METHODS

Cervical sensorimotor control was assessed by a head repositioning task in 24 patients with CD and 70 asymptomatic controls. Blindfolded participants were asked to reposition their head to a previously memorized neutral head position (NHP) following an active movement (flexion, extension, left, and right rotation). The repositioning error (joint position error, JPE) was registered via 3D motion analysis with an eight-camera infrared system (VICON ® T10). Disease-specific characteristics of all patients were obtained via the Tsui scale, Cervical Dystonia Impact Profile (CDIP-58), and Toronto Western Spasmodic Rating Scale.

RESULTS

Patients with CD showed larger JPE than controls (mean difference of 1.5°, p < .006), and systematically 'overshoot', i.e. surpassed the NHP, whereas control subjects 'undershoot', i.e. fall behind the NHP. The JPE did not correlate with disease-specific characteristics.

CONCLUSIONS

Cervical sensorimotor control is impaired in patients with CD. As cervical sensorimotor control can be trained, this might be a potential treatment option for therapy, adjuvant to botulinum toxin injections.

Physiology of midbrain head movement neurons in cervical dystonia

BACKGROUND

Early theories for cervical dystonia, as promoted by Hassler, emphasized the role of the midbrain interstitial nucleus of Cajal. Focus then shifted to the basal ganglia, and it was further supported with the success of deep brain stimulation. Contemporary theories suggested the role of the cerebellum, but even more recent hypotheses renewed interest in the midbrain. Although the pretectum was visited on several occasions, we still do not know about the physiology of midbrain neurons in cervical dystonia.

METHODS

We analyzed the unique database of pretectal neurons collected in the 1970s and 1980s during historic stereotactic surgeries aimed to treat cervical dystonia. This database is valuable because such recordings could otherwise never be obtained from humans.

RESULTS

We found the following 3 types of eye or neck movement sensitivity: eye-only neurons responded to pure vertical eye movements, neck-only neurons were sensitive to pure neck movements, and the combined eye-neck neurons responded to eye and neck movements. There were the 2 neuronal subtypes: burst-tonic and tonic. The eye-neck or eye-only neurons sustained their activity during eccentric gaze holding. In contrast, the response of neck-only and eye-neck neurons exponentially decayed during neck movements.

CONCLUSIONS

Modern quantitative analysis of a historic database of midbrain single units from patients with cervical dystonia might support novel hypotheses for normal and abnormal head movements. This data, collected almost 4 decades ago, must be carefully viewed, especially because it was acquired using a less sophisticated technology available at that time and the aim was not to address specific hypothesis, but to make an accurate lesion providing optimal relief from dystonia. © 2017 International Parkinson and Movement Disorder Society.

Distinct neural circuits for control of movement vs. holding still

In generating a point-to-point movement, the brain does more than produce the transient commands needed to move the body part; it also produces the sustained commands that are needed to hold the body part at its destination. In the oculomotor system, these functions are mapped onto two distinct circuits: a premotor circuit that specializes in generating the transient activity that displaces the eyes and a "neural integrator" that transforms that transient input into sustained activity that holds the eyes. Different parts of the cerebellum adaptively control the motor commands during these two phases: the oculomotor vermis participates in fine tuning the transient neural signals that move the eyes, monitoring the activity of the premotor circuit via efference copy, whereas the flocculus participates in controlling the sustained neural signals that hold the eyes, monitoring the activity of the neural integrator. Here, I review the oculomotor literature and then ask whether this separation of control between moving and holding is a design principle that may be shared with other modalities of movement. To answer this question, I consider neurophysiological and psychophysical data in various species during control of head movements, arm movements, and locomotion, focusing on the brain stem, motor cortex, and hippocampus, respectively. The review of the data raises the possibility that across modalities of motor control, circuits that are responsible for producing commands that change the sensory state of a body part are distinct from those that produce commands that maintain that sensory state.

Cerebellar Intermittent Theta-Burst Stimulation and Motor Control Training in Individuals with Cervical Dystonia

Background: There is emerging evidence that cervical dystonia is a neural network disorder with the cerebellum as a key node. The cerebellum may provide a target for neuromodulation as a therapeutic intervention in cervical dystonia. Objective: This study aimed to assess effects of intermittent theta-burst stimulation of the cerebellum on dystonia symptoms, quality of life, hand motor dexterity and cortical neurophysiology using transcranial magnetic stimulation. Methods: Sixteen participants with cervical dystonia were randomised into real or sham stimulation groups. Cerebellar neuromodulation was combined with motor training for the neck and an implicit learning task. The intervention was delivered over 10 working days. Outcome measures included dystonia severity and pain, quality of life, hand dexterity, and motor-evoked potentials and cortical silent periods recorded from upper trapezius muscles. Assessments were taken at baseline and after 5 and 10 days, with quality of life also measured 4 and 12 weeks later. Results: Intermittent theta-burst stimulation improved dystonia severity (Day 5, −5.44 points; p = 0.012; Day 10, −4.6 points; p = 0.025), however, effect sizes were small. Quality of life also improved (Day 5, −10.6 points, p = 0.012; Day 10, −8.6 points, p = 0.036; Week 4, −12.5 points, p = 0.036; Week 12, −12.4 points, p = 0.025), with medium or large effect sizes. There was a reduction in time to complete the pegboard task pre to post intervention (both p < 0.008). Cortical neurophysiology was unchanged by cerebellar neuromodulation. Conclusion: Intermittent theta-burst stimulation of the cerebellum may improve cervical dystonia symptoms, upper limb motor control and quality of life. The mechanism likely involves promoting neuroplasticity in the cerebellum although the neurophysiology remains to be elucidated. Cerebellar neuromodulation may have potential as a novel treatment intervention for cervical dystonia, although larger confirmatory studies are required.

A Functional Magnetic Resonance Imaging Study of Head Movements in Cervical Dystonia

Cervical dystonia (CD) is a neurological disorder characterized by abnormal movements and postures of the head. The brain regions responsible for these abnormal movements are not well understood, because most imaging techniques for assessing regional brain activity cannot be used when the head is moving. Recently, we mapped brain activation in healthy individuals using functional magnetic resonance imaging during isometric head rotation, when muscle contractions occur without actual head movements. In the current study, we used the same methods to explore the neural substrates for head movements in subjects with CD who had predominantly rotational abnormalities (torticollis). Isometric wrist extension was examined for comparison. Electromyography of neck and hand muscles ensured compliance with tasks during scanning, and any head motion was measured and corrected. Data were analyzed in three steps. First, we conducted within-group analyses to examine task-related activation patterns separately in subjects with CD and in healthy controls. Next, we directly compared task-related activation patterns between participants with CD and controls. Finally, considering that the abnormal head movements in CD occur in a consistently patterned direction for each individual, we conducted exploratory analyses that involved normalizing data according to the direction of rotational CD. The between-group comparisons failed to reveal any significant differences, but the normalization procedure in subjects with CD revealed that isometric head rotation in the direction of dystonic head rotation was associated with more activation in the ipsilateral anterior cerebellum, whereas isometric head rotation in the opposite direction was associated with more activity in sensorimotor cortex. These findings suggest that the cerebellum contributes to abnormal head rotation in CD, whereas regions in the cerebral cortex are involved in opposing the involuntary movements.

Application of virtual reality head mounted display for investigation of movement: a novel effect of orientation of attention

OBJECTIVE

To date human kinematics research has relied on video processing, motion capture and magnetic search coil data acquisition techniques. However, the use of head mounted display virtual reality systems, as a novel research tool, could facilitate novel studies into human movement and movement disorders. These systems have the unique ability of presenting immersive 3D stimulus while also allowing participants to make ecologically valid movement-based responses.

APPROACH

We employed one such system (Oculus Rift DK2) in this study to present visual stimulus and acquire head-turn data from a cohort of 40 healthy adults. Participants were asked to complete head movements towards eccentrically located visual targets following valid and invalid cues. Such tasks are commonly employed for investigating the effects orientation of attention and are known as Posner cueing paradigms. Electrooculography was also recorded for a subset of 18 participants.

MAIN RESULTS

A delay was observed in onset of head movement and saccade onset during invalid trials, both at the group and single participant level. We found that participants initiated head turns 57.4 ms earlier during valid trials. A strong relationship between saccade onset and head movement onset was also observed during valid trials.

SIGNIFICANCE

This work represents the first time that the Posner cueing effect has been observed in onset of head movement in humans. The results presented here highlight the role of head-mounted display systems as a novel and practical research tool for investigations of normal and abnormal movement patterns.

Cervical dystonia: a neural integrator disorder

Ocular motor neural integrators ensure that eyes are held steady in straight-ahead and eccentric positions of gaze. Abnormal function of the ocular motor neural integrator leads to centripetal drifts of the eyes with consequent gaze-evoked nystagmus. In 2002 a neural integrator, analogous to that in the ocular motor system, was proposed for the control of head movements. Recently, a counterpart of gaze-evoked eye nystagmus was identified for head movements; in which the head could not be held steady in eccentric positions on the trunk. These findings lead to a novel pathophysiological explanation in cervical dystonia, which proposed that the abnormalities of head movements stem from a malfunctioning head neural integrator, either intrinsically or as a result of impaired cerebellar, basal ganglia, or peripheral feedback. Here we briefly recapitulate the history of the neural integrator for eye movements, then further develop the idea of a neural integrator for head movements, and finally discuss its putative role in cervical dystonia. We hypothesize that changing the activity in an impaired head neural integrator, by modulating feedback, could treat dystonia.

Multiple Time Courses of Vestibular Set-Point Adaptation Revealed by Sustained Magnetic Field Stimulation of the Labyrinth

A major focus in neurobiology is how the brain adapts its motor behavior to changes in its internal and external environments [1, 2]. Much is known about adaptively optimizing the amplitude and direction of eye and limb movements, for example, but little is known about another essential form of learning, "set-point" adaptation. Set-point adaptation balances tonic activity so that reciprocally acting, agonist and antagonist muscles have a stable platform from which to launch accurate movements. Here, we use the vestibulo-ocular reflex-a simple behavior that stabilizes the position of the eye while the head is moving-to investigate how tonic activity is adapted toward a new set point to prevent eye drift when the head is still [3, 4]. Set-point adaptation was elicited with magneto-hydrodynamic vestibular stimulation (MVS) by placing normal humans in a 7T MRI for 90 min. MVS is ideal for prolonged labyrinthine activation because it mimics constant head acceleration and induces a sustained nystagmus similar to natural vestibular lesions [5, 6]. The MVS-induced nystagmus diminished slowly but incompletely over multiple timescales. We propose a new adaptation hypothesis, using a cascade of imperfect mathematical integrators, that reproduces the response to MVS (and more natural chair rotations), including the gradual decrease in nystagmus as the set point changes over progressively longer time courses. MVS set-point adaptation is a biological model with applications to basic neurophysiological research into all types of movements [7], functional brain imaging [8], and treatment of vestibular and higher-level attentional disorders by introducing new biases to counteract pathological ones [9].

Abnormal head oscillations in neuro-ophthalmology and neuro-otology

PURPOSE OF REVIEW

The study describes the clinical phenomenology and contemporary pathophysiology of concurrent oscillations of the eyes and the head that are present in neurological conditions with diverse causes.

RECENT FINDINGS

One classic example is spasmus nutans in which the eye oscillations are the primary cause, whereas head nodding is thought to be an operant conditional response that suppresses the eye oscillations to facilitate clear vision. The second example is a combination of head tremor and inadequate compensatory eye movements because of vestibular hypofunction leading to the illusion of pendular nystagmus - hence, the condition is called pseudonystagmus. Cerebellar degeneration in ataxia-telangiectasia or synchronized spontaneous discharge from the inferior olive and cerebellum in the syndrome of ocular palatal tremor with dystonia are examples of eye and head oscillations because of the impairment in cerebellar outflow. Infantile nystagmus syndrome also presents with eye and head oscillations, but here the relationship between the two types of oscillations differs among patients and is still unclear.

SUMMARY

The clinical features and putative pathophysiology of diverse disorders of the eyes and head that produce unwanted oscillations are reviewed. Key clinical pearls that are essential to separate these disorders at the bedside are also emphasized.

Head Tracking of Auditory, Visual, and Audio-Visual Targets

The ability to actively follow a moving auditory target with our heads remains unexplored even though it is a common behavioral response. Previous studies of auditory motion perception have focused on the condition where the subjects are passive. The current study examined head tracking behavior to a moving auditory target along a horizontal 100° arc in the frontal hemisphere, with velocities ranging from 20 to 110°/s. By integrating high fidelity virtual auditory space with a high-speed visual presentation we compared tracking responses of auditory targets against visual-only and audio-visual "bisensory" stimuli. Three metrics were measured-onset, RMS, and gain error. The results showed that tracking accuracy (RMS error) varied linearly with target velocity, with a significantly higher rate in audition. Also, when the target moved faster than 80°/s, onset and RMS error were significantly worst in audition the other modalities while responses in the visual and bisensory conditions were statistically identical for all metrics measured. Lastly, audio-visual facilitation was not observed when tracking bisensory targets.

Quantifying saccades while walking: validity of a novel velocity-based algorithm for mobile eye tracking

We validate a novel algorithm to detect saccades from raw data obtained during walking from a mobile infra-red eye-tracking device. The algorithm was based on a velocity threshold detection method, which excluded artefacts such as blinks and flickers using specific criteria. Mobile infra-red eye-tracking was performed with a group of healthy older adults (n=5) and Parkinson's disease (n=5) subjects. Saccades determined from raw eye tracker data obtained during walking using the algorithm were compared to a ground truth dataset defined as frame-by-frame visual inspection of raw eye-tracking videos. 100 trials from 10 subjects were analyzed and compared. The algorithm was highly reliable when compared to the ground truth (ICC(2,1) = 0.94), with an overall correct saccade detection percentage of 85%. This provides a simple yet robust algorithm for the analysis of mobile eye-tracking data.

Oscillatory head movements in cervical dystonia: Dystonia, tremor, or both?

Cervical dystonia is characterized by abnormal posturing of the head, often combined with tremor-like oscillatory head movements. The nature and source of these oscillatory head movements is controversial, so they were quantified to delineate their characteristics and develop a hypothetical model for their genesis. A magnetic search coil system was used to measure head movements in 14 subjects with cervical dystonia. Two distinct types of oscillatory head movements were detected for most subjects, even when they were not clinically evident. One type had a relatively large amplitude and jerky irregular pattern, and the other had smaller amplitude with a more regular and sinusoidal pattern. The kinematic properties of these two types of oscillatory head movements were distinct, although both were often combined in the same subject. Both had features suggestive of a defect in a central neural integrator. The combination of different types of oscillatory head movements in cervical dystonia helps to clarify some of the current debates regarding whether they should be considered as manifestations of dystonia or tremor and provides novel insights into their potential pathogenesis.

Long-lasting effects of neck muscle vibration and contraction on self-motion perception of vestibular origin

OBJECTIVE

To show that neck proprioceptive input can induce long-term effects on vestibular-dependent self-motion perception.

METHODS

Motion perception was assessed by measuring the subject's error in tracking in the dark the remembered position of a fixed target during whole-body yaw asymmetric rotation of a supporting platform, consisting in a fast rightward half-cycle and a slow leftward half-cycle returning the subject to the initial position. Neck muscles were relaxed or voluntarily contracted, and/or vibrated. Whole-body rotation was administered during or at various intervals after the vibration train. The tracking position error (TPE) at the end of the platform rotation was measured during and after the muscle conditioning maneuvers.

RESULTS

Neck input produced immediate and sustained changes in the vestibular perceptual response to whole-body rotation. Vibration of the left sterno-cleido-mastoideus (SCM) or right splenius capitis (SC) or isometric neck muscle effort to rotate the head to the right enhanced the TPE by decreasing the perception of the slow rotation. The reverse effect was observed by activating the contralateral muscle. The effects persisted after the end of SCM conditioning, and slowly vanished within several hours, as tested by late asymmetric rotations. The aftereffect increased in amplitude and persistence by extending the duration of the vibration train (from 1 to 10min), augmenting the vibration frequency (from 5 to 100Hz) or contracting the vibrated muscle. Symmetric yaw rotation elicited a negligible TPE, upon which neck muscle vibrations were ineffective.

CONCLUSIONS

Neck proprioceptive input induces enduring changes in vestibular-dependent self-motion perception, conditional on the vestibular stimulus feature, and on the side and the characteristics of vibration and status of vibrated muscles. This shows that our perception of whole-body yaw-rotation is not only dependent on accurate vestibular information, but is modulated by proprioceptive information related to previously experienced position of head with respect to trunk.

SIGNIFICANCE

Tonic proprioceptive inflow, as might occur as a consequence of enduring or permanent head postures, can induce adaptive plastic changes in vestibular-dependent motion sensitiveness. These changes might be counteracted by vibration of selected neck muscles.

Cervical dystonia: a disorder of the midbrain network for covert attentional orienting

While the pathogenesis of cervical dystonia remains unknown, recent animal and clinical experimental studies have indicated its probable mechanisms. Abnormal temporal discrimination is a mediational endophenotype of cervical dystonia and informs new concepts of disease pathogenesis. Our hypothesis is that both abnormal temporal discrimination and cervical dystonia are due to a disorder of the midbrain network for covert attentional orienting caused by reduced gamma-aminobutyric acid (GABA) inhibition, resulting, in turn, from as yet undetermined, genetic mutations. Such disinhibition is (a) subclinically manifested by abnormal temporal discrimination due to prolonged duration firing of the visual sensory neurons in the superficial laminae of the superior colliculus and (b) clinically manifested by cervical dystonia due to disinhibited burst activity of the cephalomotor neurons of the intermediate and deep laminae of the superior colliculus. Abnormal temporal discrimination in unaffected first-degree relatives of patients with cervical dystonia represents a subclinical manifestation of defective GABA activity both within the superior colliculus and from the substantia nigra pars reticulata. A number of experiments are required to prove or disprove this hypothesis.

A novel presentation of an ocular geste antagoniste in cervical dystonia: a case report

BACKGROUND

A geste antagoniste or sensory trick is a well described phenomenon associated with primary cervical dystonia. Craniocervical tactile stimulation or stereotyped limb movements allow patients to transiently ameliorate dystonic activation of cervical musculature.

CASE REPORT

We report a patient with primary cervical dystonia who presented with a novel "ocular" geste antagoniste. Through a sensory trick of tonic left eye deviation, the patient transiently reduces cervical dystonic activity (improved range of motion and reduced dystonic tremor). Multi-channel surface electromyography and video are used to illustrate these findings.

DISCUSSION

This case presents a unique clinical observation of specific voluntary eye movements attenuating cervical dystonia. The phenomenon is phenotypically consistent with previously described limb sensorimotor tricks.