tDCS application for postural control in Parkinson's disease: Effects are associated with baseline characteristics

INTRODUCTION

Transcranial direct current stimulation (tDCS) improves postural response to perturbation in patients with Parkinson's disease (PwPD). However, the influence of baseline characteristics such as clinical/cognitive and postural performance on the response to tDCS remains unclear.

OBJECTIVE

To investigate whether baseline level of postural control (performance during sham condition) and clinical/cognitive characteristics are associated with tDCS-related changes in postural responses to external perturbations in PwPD.

METHODS

Twenty-four PwPD participated in this study. Clinical assessment included disease severity, disease duration, levodopa equivalent dose and global cognition. Anodal tDCS protocols targeting the primary motor cortex were applied in two separate sessions (at least 2 weeks apart): active (2 mA for 20 min) and sham stimulation. Seven trials with the backward translation of the support base (20 cm/s and 5 cm) were performed after tDCS. Postural outcomes included the recovery time to stable position and onset latency of the medial gastrocnemius (MG). Pearson and Spearman correlation tests were performed.

RESULTS

No significant correlations were observed between clinical/cognitive characteristics and tDCS-related changes in postural responses. Negative associations were observed between the baseline level of postural control and tDCS-related changes in postural responses for the recovery time (r = -0.657; p < 0.001) and the MG onset latency (rs = -0.539; p = 0.007). PwPD with worse baseline postural control demonstrated greater improvement after active stimulation.

CONCLUSIONS

Findings suggest that tDCS-related effects on postural response to perturbation are related to the baseline level of postural control, but not to clinical characteristics in PwPD. Those with worse baseline postural control responded better to tDCS.

Prefrontal Cortical Activity During Preferred and Fast Walking in Young and Older Adults: An fNIRS Study

Age-related changes may affect the performance during fast walking speed. Although, several studies have been focused on the contribution of the prefrontal cortex (PFC) during challenging walking tasks, the neural mechanism underling fast walking speed in older people remain poorly understood. Therefore, the aim of this study was to investigate the influence of aging on PFC activity during overground walking at preferred and fast speeds. Twenty-five older adults (67.37 ± 5.31 years) and 24 young adults (22.70 ± 1.30 years) walked overground in two conditions: preferred speed and fast walking speed. Five trials were performed for each condition. A wireless functional near-infrared spectroscopy (fNIRS) system measured PFC activity. Gait parameters were evaluated using the GAITRite system. Overall, older adults presented higher PFC activity than young adults in both conditions. Speed-related change in PFC activity was observed for older adults, but not for young adults. Older adults significantly increased activity in the left PFC from the preferred to fast walking condition whereas young adults had similar levels of PFC activity across conditions. Our findings suggest that older adults need to recruit additional prefrontal cognitive resources to control walking, indicating a compensatory mechanism. In addition, left PFC seems to be involved in the modulation of gait speed in older adults.

Aerobic Exercise Combined With Transcranial Direct Current Stimulation Over the Prefrontal Cortex in Parkinson Disease: Effects on Cortical Activity, Gait, and Cognition

BACKGROUND

Since people with Parkinson disease (PD) rely on limited prefrontal executive resources for the control of gait, interventions targeting the prefrontal cortex (PFC) may help in managing PD-related gait impairments. Transcranial direct current stimulation (tDCS) can be used to modulate PFC excitability and improve prefrontal cognitive functions and gait.

OBJECTIVE

We investigated the effects of adding anodal tDCS applied over the PFC to a session of aerobic exercise on gait, cognition, and PFC activity while walking in people with PD.

METHODS

A total of 20 people with PD participated in this randomized, double-blinded, sham-controlled crossover study. Participants attended two 30-minute sessions of aerobic exercise (cycling at moderate intensity) combined with different tDCS conditions (active- or sham-tDCS), 1 week apart. The order of sessions was counterbalanced across the sample. Anodal tDCS (2 mA for 20 minutes [active-tDCS] or 10 s [sham-tDCS]) targeted the PFC in the most affected hemisphere. Spatiotemporal gait parameters, cognitive functions, and PFC activity while walking were assessed before and immediately after each session.

RESULTS

Compared with the pre-assessment, participants decreased step time variability (effect size: -0.4), shortened simple and choice reaction times (effect sizes: -0.73 and -0.57, respectively), and increased PFC activity in the stimulated hemisphere while walking (effect size: 0.54) only after aerobic exercise + active-tDCS.

CONCLUSION

The addition of anodal tDCS over the PFC to a session of aerobic exercise led to immediate positive effects on gait variability, processing speed, and executive control of walking in people with PD.

Cortical Activity Underlying Gait Improvements Achieved With Dopaminergic Medication During Usual Walking and Obstacle Avoidance in Parkinson Disease

BACKGROUND

Dopaminergic medication improves gait in people with Parkinson disease (PD). However, it remains unclear if dopaminergic medication modulates cortical activity while walking.

OBJECTIVE

We investigated the effects of dopaminergic medication on cortical activity during unobstructed walking and obstacle avoidance in people with PD.

METHODS

A total of 23 individuals with PD, in both off (PD_OFF) and on (PD_ON) medication states, and 30 healthy older adults (control group [CG]) performed unobstructed walking and obstacle avoidance conditions. Cortical activity was acquired through a combined functional near-infrared spectroscopy electroencephalography (EEG) system, along with gait parameters, through an electronic carpet. Prefrontal cortex (PFC) oxygenated hemoglobin (HbO₂) and EEG absolute power from FCz, Cz, and CPz channels were calculated.

RESULTS

HbO₂ concentration reduced for people with PD_OFF during obstacle avoidance compared with unobstructed walking. In contrast, both people with PD_ON and the CG had increased HbO₂ concentration when avoiding obstacles compared with unobstructed walking. Dopaminergic medication increased step length, step velocity, and β and γ power in the CPz channel, regardless of walking condition. Moreover, dopaminergic-related changes (ie, on-off) in FCz/CPz γ power were associated with dopaminergic-related changes in step length for both walking conditions.

CONCLUSIONS

PD compromises the activation of the PFC during obstacle avoidance, and dopaminergic medication facilitates its recruitment. In addition, PD medication increases sensorimotor integration during walking by increasing posterior parietal cortex (CPz) activity. Increased γ power in the CPz and FCz channels is correlated with step length improvements achieved with dopaminergic medication during unobstructed walking and obstacle avoidance in PD.

Center of pressure responses to unpredictable external perturbations indicate low accuracy in predicting fall risk in people with Parkinson's disease

Falls are associated with impairment in postural control in people with Parkinson's disease (PwPD). We aimed to predict the fall risk through models combining postural responses with clinical and cognitive measures. Also, we compared the center of pressure (CoP) between PwPD fallers and non-fallers after unpredictable external perturbations. We expected that CoP parameters combined with clinical and cognitive measures would predict fall risk. Seventy-five individuals participated in the study. CoP parameters were measured during postural responses through five trials with unpredictable translations of the support-surface in posterior direction. Range and peak of CoP were analyzed in two periods: early and late responses. Time to peak (negative peak) and recovery time were analyzed regardless of the periods. Models included the CoP parameters in early (model 1), late responses (model 2), and temporal parameters (model 3). Clinical and cognitive measures were entered into all models. Twenty-nine participants fell at least once, and 46 PwPD did not fall during 12 months following the postural assessment. Range of CoP in late responses was associated with fall risk (p = .046). However, although statistically non-significant, this parameter indicated low accuracy in predicting fall risk (area under the curve = 0.58). Fallers presented a higher range of CoP in early responses than non-fallers (p = .033). In conclusion, although an association was observed between fall risk and range of CoP in late responses, this parameter indicated low accuracy in predicting fall risk in PwPD. Also, fallers demonstrate worse postural control during early responses after external perturbations than non-fallers, measured by CoP parameters.

Effect of Different Intensities of Transcranial Direct Current Stimulation on Postural Response to External Perturbation in Patients With Parkinson’s Disease

Background

Habituation of postural response to perturbations is impaired in people with Parkinson’s disease (PD) due to deficits in cortico-basal pathways. Although transcranial direct current stimulation (tDCS) modulate cortico-basal networks, it remains unclear if it can benefit postural control in PD.

Objective

To analyze the effect of different intensities of anodal tDCS on postural responses and prefrontal cortex (PFC) activity during the habituation to the external perturbation in patients with PD (n = 24).

Methods

Anodal tDCS was applied over the primary motor cortex (M1) with 1 mA, 2 mA, and sham stimulation in 3 different sessions (~2 weeks apart) during 20 minutes immediately before the postural assessment. External perturbation (7 trials) was applied by a support base posterior translation (20 cm/s and 5 cm). Primary outcome measures included lower limb electromyography and center of pressure parameters. Measures of PFC activity are reported as exploratory outcomes. Analyses of variance (Stimulation Condition × Trial) were performed.

Results

Habituation of perturbation was evidenced independent of the stimulation conditions. Both active stimulation intensities had shorter recovery time and a trend for lower cortical activity in the stimulated hemisphere when compared to sham condition. Shorter onset latency of the medial gastrocnemius as well as lower cortical activity in the nonstimulated hemisphere were only observed after 2 mA concerning the sham condition.

Conclusions

tDCS over M1 improved the postural response to external perturbation in PD, with better response observed for 2 mA compared with 1 mA. However, tDCS seems to be inefficient in modifying the habituation of perturbation.

Prefrontal Cortex Activity During Walking: Effects of Aging and Associations With Gait and Executive Function

Background

Declines in gait parameters are common with aging and more pronounced in tasks with increased executive demand. However, the neural correlates of age-related gait impairments are not fully understood yet.

Objectives

To investigate ( a) the effects of aging on prefrontal cortex (PFC) activity and gait parameters during usual walking, obstacle crossing and dual-task walking and ( b) the association between PFC activity and measures of gait and executive function.

Methods

Eighty-eight healthy individuals were distributed into 6 age-groups: 20-25 (G20), 30-35 (G30), 40-45 (G40), 50-55 (G50), 60-65 (G60), and 70-75 years (G70). Participants walked overground under 3 conditions: usual walking, obstacle crossing, and dual-task walking. Changes in oxygenated and deoxygenated hemoglobin in the PFC were recorded using functional near-infrared spectroscopy. Gait spatiotemporal parameters were assessed using an electronic walkway. Executive function was assessed through validated tests.

Results

Between-group differences on PFC activity were observed for all conditions. Multiple groups (ie, G30, G50, G60, and G70) showed increased PFC activity in at least one of the walking conditions. Young adults (G20 and G30) had the lowest levels of PFC activity while G60 had the highest levels. Only G70 showed reduced executive function and gait impairments (which were more pronounced during obstacle crossing and dual-task walking). PFC activity was related to gait and executive function.

Conclusions

Aging causes a gradual increase in PFC activity during walking. This compensatory mechanism may reach the resource ceiling in the 70s, when reduced executive function limits its efficiency and gait impairments are observed.

Is Cortical Activation During Walking Different Between Parkinson’s Disease Motor Subtypes?

Parkinson’s disease (PD) is often classified into tremor dominant (TD) and postural instability gait disorder (PIGD) subtypes. Degeneration of subcortical/cortical pathways is different between PD subtypes, which leads to differences in motor behavior. However, the influence of PD subtype on cortical activity during walking remains poorly understood. Therefore, we aimed to investigate the influence of PD motor subtypes on cortical activity during unobstructed walking and obstacle avoidance. Seventeen PIGD and 19 TD patients performed unobstructed walking and obstacle avoidance conditions. Brain activity was measured using a mobile functional near-infrared spectroscopy–electroencephalography (EEG) systems, and gait parameters were analyzed using an electronic carpet. Concentrations of oxygenated hemoglobin (HbO2) of the prefrontal cortex (PFC) and EEG absolute power from alpha, beta, and gamma bands in FCz, Cz, CPz, and Oz channels were calculated. These EEG channels correspond to supplementary motor area, primary motor cortex, posterior parietal cortex, and visual cortex, respectively. Postural instability gait disorder patients presented higher PFC activity than TD patients, regardless of the walking condition. Tremor dominant patients presented reduced beta power in the Cz channel during obstacle avoidance compared to unobstructed walking. Both TD and PIGD patients decreased alpha and beta power in the FCz and CPz channels. In conclusion, PIGD patients need to recruit additional cognitive resources from the PFC for walking. Both TD and PIGD patients presented changes in the activation of brain areas related to motor/sensorimotor areas in order to maintain balance control during obstacle avoidance, being that TD patients presented further changes in the motor area (Cz channel) to avoid obstacles.

Transcranial direct current stimulation combined with physical or cognitive training in people with Parkinson's disease: a systematic review

BACKGROUND

Pharmacologic therapy is the primary treatment used to manage Parkinson's disease (PD) symptoms. However, it becomes less effective with time and some symptoms do not respond to medication. Complementary interventions are therefore required for PD. Recent studies have implemented transcranial direct current stimulation (tDCS) in combination with other modalities of interventions, such as physical and cognitive training. Although the combination of tDCS with physical and cognitive training seems promising, the existing studies present mixed results. Therefore, a systematic review of the literature is necessary.

AIMS

This systematic review aims to (i) assess the clinical effects of tDCS when applied in combination with physical or cognitive therapies in people with PD and; (ii) analyze how specific details of the intervention protocols may relate to findings.

METHODS

The search strategy detailed the technique of stimulation, population and combined interventions (i.e. cognitive and/or physical training). Only controlled studies were included.

RESULTS

Seventeen of an initial yield of 408 studies satisfied the criteria. Studies involved small sample sizes. tDCS protocols and characteristics of combined interventions varied. The reviewed studies suggest that synergistic effects may be obtained for cognition, upper limb function, gait/mobility and posture when tDCS is combined with cognitive and/or motor interventions in PD.

CONCLUSION

The reported results encourage further research to better understand the therapeutic utility of tDCS and to inform optimal clinical use in PD. Future studies in this field should focus on determining optimal stimulation parameters and intervention characteristics for maximal benefits in people with PD.

Levodopa Facilitates Prefrontal Cortex Activation During Dual Task Walking in Parkinson Disease

Background. Although dopaminergic medication improves dual task walking in people with Parkinson disease (PD), the underlying neural mechanisms are not yet fully understood. As prefrontal cognitive resources are involved in dual task walking, evaluation of the prefrontal cortex (PFC) is required. Objective. To investigate the effect of dopaminergic medication on PFC activity and gait parameters during dual task walking in people with PD. Methods. A total of 20 individuals with PD (69.8 ± 5.9 years) and 30 healthy older people (68.0 ± 5.6 years) performed 2 walking conditions: single and dual task (walking while performing a digit vigilance task). A mobile functional near infrared spectroscopy system and an electronic sensor carpet were used to analyze PFC activation and gait parameters, respectively. Relative concentrations of oxygenated hemoglobin (HbO2) from the left and right PFC were measured. Results. People with PD in the off state did not present changes in HbO2 level in the left PFC across walking conditions. In contrast, in the on state, they presented increased HbO2 levels during dual task compared with single task. Regardless of medication state, people with PD presented increased HbO2 levels in the right PFC during dual task walking compared with single task. The control group demonstrated increased PFC activity in both hemispheres during dual task compared with single task. People with PD showed increases in both step length and velocity in the on state compared with the off state. Conclusions. PD limits the activation of the left PFC during dual task walking, and dopaminergic medication facilitates its recruitment.

Usual walking and obstacle avoidance are influenced by depressive and anxiety symptoms in patients with Parkinson's disease

AIM

The aim of the present study was to analyze the association of depressive and anxiety symptoms with usual walking and obstacle avoidance in patients with Parkinson's disease.

METHODS

Patients were divided into three groups: without depressive and anxiety symptoms (n = 28); depressive symptoms only (n = 15); and depressive and anxiety symptoms (n = 19). Symptoms of depression and anxiety were evaluated by the Hospital Anxiety and Depression scale. Participants walked across a pathway in two experimental conditions: usual walking and obstacle avoidance. Kinematic data were recorded using an optoelectronic three-dimensional system.

RESULTS

During usual walking, the depressive and anxiety symptoms group presented shorter stride length and longer double support phase compared with the without depressive and anxiety symptoms group, and lower velocity than the without depressive and anxiety symptoms and depressive symptoms groups. During the approach phase of obstacle avoidance, the depressive and anxiety symptoms group decreased the stride length and velocity, whereas the without depressive and anxiety symptoms and depressive symptoms groups did not modulate these parameters. The depressive and anxiety symptoms group also showed shorter step length and velocity, longer step duration, and wider step width during obstacle crossing. Additionally, the depressive and anxiety symptoms group presented shorter foot-to-obstacle horizontal distances, and lower horizontal mean velocities during obstacle crossing. Partial correlation analyses showed that both depressive and anxiety symptoms were associated with spatiotemporal gait parameters.

CONCLUSION

Combined symptoms of depression and anxiety are associated with walking impairments in patients with Parkinson's disease in both usual walking and obstacle avoidance. Geriatr Gerontol Int 2019; 19: 868-873.