Deep brain stimulation of the subthalamic and pedunculopontine nucleus in a patient with Parkinson's disease

Uncovering and leveraging the return of voluntary motor programs after paralysis using a bi-cortical neuroprosthesis

Rehabilitative and neuroprosthetic approaches after spinal cord injury (SCI) aim to reestablish voluntary control of movement. Promoting recovery requires a mechanistic understanding of the return of volition over action, but the relationship between re-emerging cortical commands and the return of locomotion is not well established. We introduced a neuroprosthesis delivering targeted bi-cortical stimulation in a clinically relevant contusive SCI model. In healthy and SCI cats, we controlled hindlimb locomotor output by tuning stimulation timing, duration, amplitude, and site. In intact cats, we unveiled a large repertoire of motor programs. After SCI, the evoked hindlimb lifts were highly stereotyped, yet effective in modulating gait and alleviating bilateral foot drag. Results suggest that the neural substrate underpinning motor recovery had traded-off selectivity for efficacy. Longitudinal tests revealed that the return of locomotion after SCI was correlated with recovery of the descending drive, which advocates for rehabilitation interventions directed at the cortical target.

Anticipatory Postural Adjustments and Compensatory Postural Responses to Multidirectional Perturbations-Effects of Medication and Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease

BACKGROUND

Postural instability is one of the most restricting motor symptoms for patients with Parkinson's disease (PD). While medication therapy only shows minor effects, it is still unclear whether medication in conjunction with deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves postural stability. Hence, the aim of this study was to investigate whether PD patients treated with medication in conjunction with STN-DBS have superior postural control compared to patients treated with medication alone.

METHODS

Three study groups were tested: PD patients on medication (PD-MED), PD patients on medication and on STN-DBS (PD-MED-DBS), and healthy elderly subjects (HS) as a reference. Postural performance, including anticipatory postural adjustments (APA) prior to perturbation onset and compensatory postural responses (CPR) following multidirectional horizontal perturbations, was analyzed using force plate and electromyography data.

RESULTS

Regardless of the treatment condition, both patient groups showed inadequate APA and CPR with early and pronounced antagonistic muscle co-contractions compared to healthy elderly subjects. Comparing the treatment conditions, study group PD-MED-DBS only showed minor advantages over group PD-MED. In particular, group PD-MED-DBS showed faster postural reflexes and tended to have more physiological co-contraction ratios.

CONCLUSION

medication in conjunction with STN-DBS may have positive effects on the timing and amplitude of postural control.

Exercise Therapies for Parkinson's Disease: A Systematic Review and Meta-Analysis

Recently, rehabilitative exercise therapies have been described as an important method of overcoming the limitations of the conventional therapies for Parkinson's disease. The present study aimed to evaluate efficacy and safety of exercise therapies for Parkinson's disease. Randomized controlled trials that evaluated exercise therapies in patients with Parkinson's disease until December 2016 were searched for in five electronic databases: PubMed, CENTRAL, EMBASE, OASIS, and CNKI. Eighteen studies (1,144 patients) were included. The overall methodological quality was not high. Patients who underwent exercise therapies exhibited statistically significant improvements in the total UPDRS, UPDRS II and III, Berg Balance Scale, preferred walking speed, and Timed Up and Go Test compared to patients who underwent nonexercise therapies. In comparison to patients who performed regular activity, patients who underwent exercise therapies exhibited statistically significant improvements in the total UPDRS, UPDRS II, and UPDRS III. Exercise therapies were found to be relatively safe. Exercise therapies might promote improvements in the motor symptoms of Parkinson's disease. However, due to the small number of randomized controlled trials and methodological limitations, we are unable to draw concrete conclusions. Therefore, further studies with better designs will be needed.

Vitexin protects dopaminergic neurons in MPTP-induced Parkinson's disease through PI3K/Akt signaling pathway

Parkinson's disease (PD) is a progressive neurodegenerative disease which is characterized by the degeneration of dopaminergic neurons in the substantia nigra pars compacta (SNpc).

METHODS

In this study, the neuroprotective effect of vitexin (Vit), a flavonoid compound isolated from Crataegus pinnatifida Bunge was examined in PD models both in vitro and in vivo.

RESULTS

On SH-SY5Y cells, methyl-4-phenylpyridine (MPP+) treatment suppressed cell viability, induced apoptosis, and increased Bax/Bcl-2 ratio and caspase-3 activity. However, Vit improved these parameters induced by MPP+ treatment significantly. Further study disclosed that Vit enhanced the phosphorylation of PI3K and Akt which was downregulated by MPP+ in SH-SY5Y cells, the effect of which could be blocked by PI3K inhibitor LY294002 and activated by PI3K activator IGF-1. Moreover, results from the pole test and traction test suggested that Vit pretreatment prevented bradykinesia and alleviated the initial lesions caused by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) in MPTP-treated mouse PD model. Vit also enhanced the activation of PI3K and Akt and suppressed the ratio of Bax/Bcl-2 and caspase-3 activity in MPTP-treated mice.

CONCLUSION

Taken together, this study demonstrated that Vit protected dopaminergic neurons against MPP+/MPTP-induced neurotoxicity through the activation of PI3K/Akt signaling pathway. Our findings may facilitate the clinical application of Vit in the therapy of PD.

Freezing of gait: Promising avenues for future treatment

Freezing of gait is a devastating symptom of Parkinson's disease and other forms of parkinsonism. It poses a major burden on both patients and their families, as freezing often leads to falls, fall-related injuries and a loss of independence. Treating freezing of gait is difficult for a variety of reasons: it has a paroxysmal and unpredictable nature; a multifaceted pathophysiology, with an interplay between motor elements (disturbed stepping mechanisms) and non-motor elements (cognitive decline, anxiety); and a complex (and likely heterogeneous) underlying neural substrate, involving multiple failing neural networks. In recent years, advances in translational neuroscience have offered new insights into the pathophysiology underlying freezing. Furthermore, the mechanisms behind the effectiveness of available treatments (or lack thereof) are better understood. Driven by these concepts, researchers and clinicians have begun to improve currently available treatment options, and develop new and better treatment methods. Here, we evaluate the range of pharmacological (i.e. closed-looped approaches), surgical (i.e. multi-target and adaptive deep brain and spinal cord stimulation) and behavioural (i.e. biofeedback and cueing on demand) treatment options that are under development, and propose novel avenues that are likely to play a crucial role in the clinical management of freezing of gait in the near future. The outcomes of this review suggest that the successful future management of freezing of gait will require individualized treatments that can be implemented in an on-demand manner in response to imminent freezing. With this review we hope to guide much-needed advances in treating this devastating symptom of Parkinson's disease.

Dopamine and the Brainstem Locomotor Networks: From Lamprey to Human

In vertebrates, dopamine neurons are classically known to modulate locomotion via their ascending projections to the basal ganglia that project to brainstem locomotor networks. An increased dopaminergic tone is associated with increase in locomotor activity. In pathological conditions where dopamine cells are lost, such as in Parkinson's disease, locomotor deficits are traditionally associated with the reduced ascending dopaminergic input to the basal ganglia. However, a descending dopaminergic pathway originating from the substantia nigra pars compacta was recently discovered. It innervates the mesencephalic locomotor region (MLR) from basal vertebrates to mammals. This pathway was shown to increase locomotor output in lampreys, and could very well play an important role in mammals. Here, we provide a detailed account on the newly found dopaminergic pathway in lamprey, salamander, rat, monkey, and human. In lampreys and salamanders, dopamine release in the MLR is associated with the activation of reticulospinal neurons that carry the locomotor command to the spinal cord. Dopamine release in the MLR potentiates locomotor movements through a D1-receptor mechanism in lampreys. In rats, stimulation of the substantia nigra pars compacta elicited dopamine release in the pedunculopontine nucleus, a known part of the MLR. In a monkey model of Parkinson's disease, a reduced dopaminergic innervation of the brainstem locomotor networks was reported. Dopaminergic fibers are also present in human pedunculopontine nucleus. We discuss the conserved locomotor role of this pathway from lamprey to mammals, and the hypothesis that this pathway could play a role in the locomotor deficits reported in Parkinson's disease.

Neuroprotective effect of matrine on MPTP-induced Parkinson's disease and on Nrf2 expression

The incidence rate of Parkinson's disease (PD) is ≤2% in Chinese individuals >65 years old, accounting for 40% of the global total of PD patients. The pathogenesis of PD is not yet clear, and oxidative stress-induced mitochondrial dysfunction is considered to be the main reason for the onset of PD. Studies have shown that matrine exhibits good antioxidant activity. Thus, the present study aimed to observe the protective effect and mechanism of matrine on 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced dopaminergic neuron damage. A total of 25 C57BL male mice were randomly divided into 5 groups, consisting of the control group (group A), the MPTP group (group B) and three matrine (4, 8 and 16 mg/kg) plus MPTP treatment groups (groups C, D and E, respectively). Results from a pole-climbing test and locomotor activity experiments were recorded. The mice were sacrificed 4 days later and brain dissection was performed. The levels of superoxide dismutase (SOD) and glutathione (GSH) were assessed. The expression level of tyrosine hydroxylase (TH) in the ventral midbrain was studied by immunofluorescence analysis. The expression level of nuclear factor erythroid 2-related factor 2 (Nrf2) in the ventral midbrain was studied by western blot analysis. The experiments were repeated three times. Compared with control mice, the PD mice exhibited the typical behaviors associated with PD; matrine can alleviate this phenomenon, and with increasing matrine concentration, the symptoms were reduced significantly. Compared with the control mice, the PD mice had lower SOD and GSH activity, and matrine partially reversed the change in SOD and GSH activity. Immunofluorescence analysis showed that the level of TH in the ventral midbrain decreased significantly in the PD mice, and that the mice administered matrine showed higher expression of TH and levels of TH-positive cells. Western blotting results showed that the expression of Nrf2 in the ventral midbrain decreased significantly in the PD mice, and that matrine was able to reverse this phenomenon. In conclusion, by promoting antioxidant-related Nrf2 signaling pathways in the ventral midbrain, matrine can inhibit the oxidative damage of dopamine neurons in PD.

Parkinson's disease as a system-level disorder

Traditionally, the basal ganglia have been considered the main brain region implicated in Parkinson’s disease. This single area perspective gives a restricted clinical picture and limits therapeutic approaches because it ignores the influence of altered interactions between the basal ganglia and other cerebral components on Parkinsonian symptoms. In particular, the basal ganglia work closely in concert with cortex and cerebellum to support motor and cognitive functions. This article proposes a theoretical framework for understanding Parkinson’s disease as caused by the dysfunction of the entire basal ganglia–cortex–cerebellum system rather than by the basal ganglia in isolation. In particular, building on recent evidence, we propose that the three key symptoms of tremor, freezing, and impairments in action sequencing may be explained by considering partially overlapping neural circuits including basal ganglia, cortical and cerebellar areas. Studying the involvement of this system in Parkinson’s disease is a crucial step for devising innovative therapeutic approaches targeting it rather than only the basal ganglia. Possible future therapies based on this different view of the disease are discussed.

Rescue Procedures after Suboptimal Deep Brain Stimulation Outcomes in Common Movement Disorders

Deep brain stimulation (DBS) is a unique, functional neurosurgical therapy indicated for medication refractory movement disorders as well as some psychiatric diseases. Multicontact electrodes are placed in "deep" structures within the brain with targets varying depending on the surgical indication. An implanted programmable pulse generator supplies the electrodes with a chronic, high frequency electrical current that clinically mimics the effects of ablative lesioning techniques. DBS's efficacy has been well established for its movement disorder indications (Parkinson's disease, essential tremor, and dystonia). However, clinical outcomes are sometimes suboptimal, even in the absence of common, potentially reversible complications such as hardware complications, infection, poor electrode placement, and poor programming parameters. This review highlights some of the rescue procedures that have been explored in suboptimal DBS cases for Parkinson's disease, essential tremor, and dystonia. To date, the data is limited and difficult to generalize, but a large majority of published reports demonstrate positive results. The decision to proceed with such treatments should be made on a case by case basis. Larger studies are needed to clearly establish the benefit of rescue procedures and to establish for which patient populations they may be most appropriate.

The Invention and Early History of the N-Localizer for Stereotactic Neurosurgery

Nearly four decades after the invention of the N-localizer, its origin and history remain misunderstood. Some are unaware that a third-year medical student invented this technology. The following conspectus accurately chronicles the origin of the N-localizer, presents recently discovered evidence that documents its history, and corrects misconceptions related to its origin and early history.

Protective Effect of Puerarin Against Oxidative Stress Injury of Neural Cells and Related Mechanisms

Background

Parkinson’s disease (PD) is manifested as degeneration of dopaminergic neurons in substantia nigra compacta. The mitochondrial dysfunction induced by oxidative stress is believed to a major cause of PD. Puerarin has been widely applied due to its estrogen nature and anti-oxidative function. This study thus investigated the protective role of puerarin against oxidative stress injury on PC12 neural cells, in addition to related mechanisms.

Material/Methods

PC12 cells were pre-treated with gradient concentrations of puerarin, followed by the induction of 0.5 mM H₂O₂. MTT assay was used to detect cell viability. Enzyme-linked immunosorbent assay (ELISA) was employed to detect intracellular level of superoxide dismutase (SOD), malondialdehyde (MDA), and glutathione (GSH). Cell apoptosis was determined by Annexin-V/7-AAD double labelling. Reactive oxidative species (ROS) and lactate dehydrogenase (LDH) activities were then measured. Cellular levels of caspase-3 and caspase-9 were also determined.

Results

The pre-treatment using puerarin significantly reversed H₂O₂-induced oxidative stress injury, as it can increase proliferation, SOD and GSH activities, decrease MDA activity, suppress apoptosis of PC12 cells, and decrease ROS and LDH production (p<0.05 in all cases). Further assays showed depressed up-regulation of caspase-3 and caspase-9 after puerarin pretreatment.

Conclusions

Puerarin pretreatment can decrease activity of caspase-3 and caspase-9 activity in PC12 cells, thus protecting cells from oxidative injury.