Sensory timing cues improve akinesia of grasping movements in Parkinson's disease: A comparison to the effects of subthalamic nucleus stimulation

Reverse Visually Guided Reaching in Patients with Parkinson’s Disease

In addition to motor symptoms such as difficulty in movement initiation and bradykinesia, patients with Parkinson’s disease (PD) display nonmotor executive cognitive dysfunction with deficits in inhibitory control. Preoperative psychological assessments are used to screen for impulsivity that may be worsened by deep brain stimulation (DBS) of the subthalamic nucleus (STN). However, it is unclear whether anti-Parkinson’s therapy, such as dopamine replacement therapy (DRT) or DBS, which has beneficial effects on motor function, adversely affects inhibitory control or its domains. The detrimental effects of STN-DBS are more apparent when tasks test the inhibition of habitual prepotent responses or involve complex cognitive loads. Our goal was to use a reverse visually guided reaching (RVGR) task, a hand-based version of the antisaccade task, to simultaneously measure motor performance and response inhibition in subjects with PD. We recruited 55 healthy control subjects, 26 PD subjects receiving treatment with DRTs, and 7 PD subjects receiving treatment with STN-DBS and DRTs. In the RVGR task, a cursor moved opposite to the subject’s hand movement. This was compared to visually guided reaching (VGR) where the cursor moved in the same direction as the subject’s hand movement. Reaction time, mean speed, and direction errors (in RVGR) were assessed. Reaction times were longer, and mean speeds were slower during RVGR compared to VGR in all three groups but worse in untreated subjects with PD. Treatment with DRTs, DBS, or DBS + DRT improved the reaction time and speed on the RVGR task to a greater extent than VGR. Additionally, DBS or DBS + DRT demonstrated an increase in direction errors, which was correlated with decreased reaction time. These results show that the RVGR task quantifies the benefit of STN-DBS on bradykinesia and the concomitant reduction of proactive inhibitory control. The RVGR task has the potential to be used to rapidly screen for preoperative deficits in inhibitory control and to titrate STN-DBS, to maximize the therapeutic benefits on movement, and minimize impaired inhibitory control.

Reaching and Grasping Movements in Parkinson's Disease: A Review

Parkinson's disease (PD) is known to affect the brain motor circuits involving the basal ganglia (BG) and to induce, among other signs, general slowness and paucity of movements. In upper limb movements, PD patients show a systematic prolongation of movement duration while maintaining a sufficient level of endpoint accuracy. PD appears to cause impairments not only in movement execution, but also in movement initiation and planning, as revealed by abnormal preparatory activity of motor-related brain areas. Grasping movement is affected as well, particularly in the coordination of the hand aperture with the transport phase. In the last fifty years, numerous behavioral studies attempted to clarify the mechanisms underlying these anomalies, speculating on the plausible role that the BG-thalamo-cortical circuitry may play in normal and pathological motor control. Still, many questions remain open, especially concerning the management of the speed-accuracy tradeoff and the online feedback control. In this review, we summarize the literature results on reaching and grasping in parkinsonian patients. We analyze the relevant hypotheses on the origins of dysfunction, by focusing on the motor control aspects involved in the different movement phases and the corresponding role played by the BG. We conclude with an insight into the innovative stimulation techniques and computational models recently proposed, which might be helpful in further clarifying the mechanisms through which PD affects reaching and grasping movements.

Increased neural motor activation and functional reorganization in patients with idiopathic rapid eye movement sleep behavior disorder

INTRODUCTION

Altered brain activity and functional reorganization patterns during self-initiated movements have been reported in early pre-motor and motor stages of Parkinson's disease. The aim of this study was to investigate whether similar alterations can be observed in patients with idiopathic REM-sleep behavior disorder (RBD).

METHODS

13 polysomnography-confirmed male and right-handed RBD patients and 13 healthy controls underwent a bilateral hand-movement fMRI task including internally selected (INT) and externally-guided (EXT) movement conditions for each hand. We examined functional activity and connectivity differences between groups and task-conditions, structural differences using voxel-based morphometry, as well as associations between functional activity and clinical variables.

RESULTS

No group differences were observed in fMRI-task performance or in voxel-based morphometry. Both groups showed faster reaction times and exhibited greater neural activation when movements were internally selected compared to externally-guided tasks. Compared to controls, RBD patients displayed stronger activation in the dorsolateral prefrontal cortex and primary somatosensory cortex during INT-tasks, and in the right fronto-insular cortex during EXT-tasks performed with the non-dominant hand. Stronger activation in RBD patients was associated with cognitive and olfactory impairment. Connectivity analysis demonstrated overall less interregional coupling in patients compared to controls. In particular, patients showed reduced temporo-cerebellar, occipito-cerebellar and intra-cerebellar connectivity, but stronger connectivity in fronto-cerebellar and fronto-occipital pathways.

CONCLUSION

The observed stronger activation during hand-movement tasks and connectivity changes in RBD may reflect early compensatory and reorganization patterns in order to preserve motor functioning. Our findings may contribute to a better understanding and prognosis of prodromal stages of α-synucleinopathies.

Reconfiguration of striatal connectivity for timing and action

The medial cortico-striatal-thalamo-cortical (CSTC) motor circuit is a core system that exerts control over interval timing and action. A common network generates these behaviors possibly owing to cellular coding of temporal and non-temporal information, which in turn promotes reconfiguration of functional connectivity in accord with behavioral goals. At the neuroanatomical level, support for flexible CSTC reconfiguration comes from studies of temporal illusions demonstrating that this system calibrates the experience of time through functional interactions with various context-sensitive brain regions. Revelations that CSTC effective connectivity is pivotal for context-dependent facets of voluntary actions, namely action planning, complement its role in predictive processes such as timing. These observations suggest that the CSTC is positioned to represent high-level information about 'what to do' and 'when to do it' by dynamically reconfiguring effective connectivity as circumstances arise.

The processing of visual and auditory information for reaching movements

Presenting target and non-target information in different modalities influences target localization if the non-target is within the spatiotemporal limits of perceptual integration. When using auditory and visual stimuli, the influence of a visual non-target on auditory target localization is greater than the reverse. It is not known, however, whether or how such perceptual effects extend to goal-directed behaviours. To gain insight into how audio-visual stimuli are integrated for motor tasks, the kinematics of reaching movements towards visual or auditory targets with or without a non-target in the other modality were examined. When present, the simultaneously presented non-target could be spatially coincident, to the left, or to the right of the target. Results revealed that auditory non-targets did not influence reaching trajectories towards a visual target, whereas visual non-targets influenced trajectories towards an auditory target. Interestingly, the biases induced by visual non-targets were present early in the trajectory and persisted until movement end. Subsequent experimentation indicated that the magnitude of the biases was equivalent whether participants performed a perceptual or motor task, whereas variability was greater for the motor versus the perceptual tasks. We propose that visually induced trajectory biases were driven by the perceived mislocation of the auditory target, which in turn affected both the movement plan and subsequent control of the movement. Such findings provide further evidence of the dominant role visual information processing plays in encoding spatial locations as well as planning and executing reaching action, even when reaching towards auditory targets.

Effects of STN DBS and auditory cueing on the performance of sequential movements and the occurrence of action tremor in Parkinson's disease

Background

Parkinson’s disease (PD) patients show a higher ability to perform repetitive movements when they are cued by external stimuli, suggesting that rhythmic synchronization with an auditory timekeeper can be achieved in the absence of intact basal ganglia function. Deep brain stimulation (DBS) is another therapeutic method that improves movement performance in PD and may suppress or enhance action tremor. However, the combined effect of these therapies on action tremor has not been studied yet. In this pilot study, we thus test the effect of both DBS in the subthalamic nucleus (STN) and auditory cueing on movement performance and action tremor.

Methods

7 PD patients treated with (bilateral) STN DBS were asked to move one hand or foot between two dots, separated by 30 cm as indicated on the table or the floor. The movement frequency was dictated by a metronome with a frequency in the range of 1.6 to 4.8 Hz. Each test was repeated three times for each extremity, with different stimulation settings applied during each repetition. The power spectral density patterns of recorded movements were studied. Tremor intermittency was taken into account by classifying each 2-second window of the recorded angular velocity signals as a tremor or non-tremor window. By determining the phase locking value it was tested whether movement or tremor was synchronized with the auditory cue.

Results

While action tremor presence or absence did not affect the level of synchronization of the movement signal with the auditory cue for the different metronome frequencies, the number of extremities showing action tremor was significantly reduced under external cueing conditions in combination with DBS. In this respect the cueing frequencies of 1.6 and 4.8 Hz showed similar effects, suggesting that the frequency of the cueing signal is not that critical.

Conclusion

The combination of deep brain stimulation and auditory cueing, which both are proposed to involve the activation of cerebellar circuits, shows an enhanced action tremor reduction in Parkinson’s disease.

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-135) contains supplementary material, which is available to authorized users.

Stimulation of the subthalamic nucleus engages the cerebellum for motor function in parkinsonian rats

Deep brain stimulation (DBS) is effective in managing motor symptoms of Parkinson's disease in well-selected individuals. Recently, research has shown that DBS in the basal ganglia (BG) can alter neural circuits beyond the traditional basal ganglia-thalamus-cortical (BG-TH-CX) loop. For instance, functional imaging showed alterations in cerebellar activity with DBS in the subthalamic nucleus (STN). However, these imaging studies revealed very little about how cell-specific cerebellar activity responds to STN stimulation or if these changes contribute to its efficacy. In this study, we assess whether STN-DBS provides efficacy in managing motor symptoms in Parkinson's disease by recruiting cerebellar activity. We do this by applying STN-DBS in hemiparkinsonian rats and simultaneously recording neuronal activity from the STN, brainstem and cerebellum. We found that STN neurons decreased spiking activity by 55% during DBS (P = 0.038), which coincided with a decrease in most pedunculopontine tegmental nucleus and Purkinje neurons by 29% (P < 0.001) and 28% (P = 0.003), respectively. In contrast, spike activity in the deep cerebellar nuclei increased 45% during DBS (P < 0.001), which was likely from reduced afferent activity of Purkinje cells. Then, we applied STN-DBS at sub-therapeutic current along with stimulation of the deep cerebellar nuclei and found similar improvement in forelimb akinesia as with therapeutic STN-DBS alone. This suggests that STN-DBS can engage cerebellar activity to improve parkinsonian motor symptoms. Our study is the first to describe how STN-DBS in Parkinson's disease alters cerebellar activity using electrophysiology in vivo and reveal a potential for stimulating the cerebellum to potentiate deep brain stimulation of the subthalamic nucleus.

Disrupted connectivity of motor loops in Parkinson's disease during self-initiated but not externally-triggered movements

Parkinson's disease (PD) reportedly includes altered connectivity of neural loops involving the basal ganglia and cerebellum, although little is known regarding any changes in the connectivity of motor loops. The goal of this study was to further understand the connectivity within the basal ganglia-thalamo-motor (BGTM) and cerebro-cerebellar (CC) loops in PD. Twelve PD patients and 12 age-matched control subjects performed a protocol involving self-initiated (SI) and externally-triggered (ET) finger movements, while being scanned with functional magnetic resonance imaging. Compared with the control subjects, the PD subjects showed hypo-activation in the bilateral putamen, right supplementary motor area and hyper-activation in the right premotor cortex. In the sensorimotor cortex and cerebellar hemisphere, PD subjects tended to show hyper-activation in a main effects analysis, but hypo-activation in a linear effects analysis. Analysis using structural equation modeling (SEM) revealed significant positive interactions within the right BGTM loop during the SI task and within the right (right cerebral hemisphere-left cerebellum) CC loop during the ET task. SEM also revealed task-related quantitative changes between the thalamus and the motor cortices in the control subjects. We found that the PD patients showed reduced connectivity in the right BGTM loop and inter-hemispheric connections in SEM, which is the first demonstration of this phenomenon. Interestingly, PD patients exhibited preserved connectivity within the right CC loop during the ET task. These results suggest disruption of cortico-striatal processing and preservation of relatively intact neural circuits that do not involve the basal ganglia in PD.

Comparison of virtual reality versus physical reality on movement characteristics of persons with Parkinson's disease: effects of moving targets

OBJECTIVE

To compare the performance of reaching for stationary and moving targets in virtual reality (VR) and physical reality in persons with Parkinson's disease (PD).

DESIGN

A repeated-measures design in which all participants reached in physical reality and VR under 5 conditions: 1 stationary ball condition and 4 conditions with the ball moving at different speeds.

SETTING

University research laboratory.

PARTICIPANTS

Persons with idiopathic PD (n=29) and age-matched controls (n=25).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Success rates and kinematics of arm movement (movement time, amplitude of peak velocity, and percentage of movement time for acceleration phase).

RESULTS

In both VR and physical reality, the PD group had longer movement time (P<.001) and lower peak velocity (P<.001) than the controls when reaching for stationary balls. When moving targets were provided, the PD group improved more than the controls did in movement time (P<.001) and peak velocity (P<.001), and reached a performance level similar to that of the controls. Except for the fastest moving ball condition (0.5-s target viewing time), which elicited worse performance in VR than in physical reality, most cueing conditions in VR elicited performance generally similar to those in physical reality.

CONCLUSIONS

Although slower than the controls when reaching for stationary balls, persons with PD increased movement speed in response to fast moving balls in both VR and physical reality. This suggests that with an appropriate choice of cueing speed, VR is a promising tool for providing visual motion stimuli to improve movement speed in persons with PD. More research on the long-term effect of this type of VR training program is needed.

Effects of virtual reality training on functional reaching movements in people with Parkinson’s disease: a randomized controlled pilot trial

Objective: To investigate whether practising reaching for virtual moving targets would improve motor performance in people with Parkinson’s disease.

Design: Randomized pretest–posttest control group design.

Setting: A virtual reality laboratory in a university setting.

Participants: Thirty-three adults with Parkinson’s disease.

Interventions: The virtual reality training required 60 trials of reaching for fast-moving virtual balls with the dominant hand. The control group had 60 practice trials turning pegs with their non-dominant hand.

Main outcome measures: Pretest and posttest required reaching with the dominant hand to grasp real stationary balls and balls moving at different speeds down a ramp. Success rates and kinematic data (movement time, peak velocity and percentage of movement time for acceleration phase) from pretest and posttest were recorded to determine the immediate transfer effects.

Results: Compared with the control group, the virtual reality training group became faster ( F = 9.08, P = 0.005) and more forceful ( F = 9.36, P = 0.005) when reaching for real stationary balls. However, there was no significant difference in success rate or movement kinematics between the two groups when reaching for real moving balls.

Conclusion: A short virtual reality training programme improved the movement speed of discrete aiming tasks when participants reached for real stationary objects. However, the transfer effect was minimal when reaching for real moving objects.

Differential involvement of striato- and cerebello-thalamo-cortical pathways in tremor- and akinetic/rigid-predominant Parkinson's disease

Parkinson's disease (PD) presents clinically with varying degrees of resting tremor, rigidity, and bradykinesia. For decades, striatal-thalamo-cortical (STC) dysfunction has been implied in bradykinesia and rigidity, but does not explain resting tremor in PD. To understand the roles of cerebello-thalamo-cortical (CTC) and STC circuits in the pathophysiology of the heterogeneous clinical presentation of PD, we collected functional magnetic resonance imaging (fMRI) data from 17 right-handed PD patients [nine tremor predominant (PDT) and eight akinetic-rigidity predominant (PDAR)] and 14 right-handed controls while they performed internally-guided (IG) sequential finger tapping tasks. The percentage of voxels activated in regions constituting the STC and CTC [divided as cerebellar hemisphere-thalamo-cortical (CHTC) and vermis-thalamo-cortical (CVTC)] circuits was calculated. Multivariate analysis of variance compared the activation patterns of these circuits between study groups. Compared to controls, both PDAR and PDT subjects displayed an overall increase in the percentage of voxels activated in both STC and CTC circuits. These increases reached statistical significance in contralateral STC and CTC circuits for PDT subjects, and in contralateral CTC pathways for PDAR subjects. Comparison of PDAR and PDT subjects revealed significant differences in ipsilateral STC (P=0.005) and CTC (P=0.043 for CHTC and P=0.003 for CVTC) circuits. These data support the differential involvement of STC and CTC circuits in PD subtypes, and help explain the heterogeneous presentation of PD symptoms. These findings underscore the importance of integrating CTC circuits in understanding PD and other disorders of the basal ganglia.

Deep brain stimulation of the subthalamic nucleus facilitates coordination of hand preshaping in Parkinson's disease

Several studies have found that Parkinson's disease (PD) disrupts the organization of complex motor sequences regardless of the influence of parkinsonian medications. A clear candidate for the neural bases of such deficits, which we term "coordinative," is the failure to integrate propioceptive and visual information by cortico-striatal circuits in a timed fashion. Recent reports, however, have indicated that deep-brain stimulation of the subthalamic nucleus (STN DBS) may result in an improvement in coordinative deficits beyond the amelioration of "intensive deficits" such as bradykinesia and scaling errors. The present study examined the spatio-temporal organization underlying the shaping of the hand during reaching to grasp objects differing in shape. Six PD patients ON and OFF their STN DBS when OFF their concomitant medications and six age-matched controls participated in this study. STN DBS improved the coordination involved in preshaping the hand while grasping. We discuss these results in light of our earlier work with PD patients on and off dopamine replacement therapy.

Dynamic changes in cerebello-thalamo-cortical motor circuitry during progression of Parkinson's disease

Both the basal ganglia and cerebellum are known to influence cortical motor and motor-associated areas via the thalamus. Whereas striato-thalamo-cortical (STC) motor circuit dysfunction has been implicated clearly in Parkinson's disease (PD), the role of the cerebello-thalamo-cortical (CTC) motor circuit has not been well defined. Functional magnetic resonance imaging (fMRI) is a convenient tool for studying the role of the CTC in vivo in PD patients, but large inter-individual differences in fMRI activation patterns require very large numbers of subjects in order to interpret data from cross-sectional, case control studies. To understand the role of the CTC during PD progression, we obtained longitudinal fMRI 2 years apart from 5 PD (57+/-8 yr) and five Controls (57+/-9 yr) performing either externally- (EG) or internally-guided (IG) sequential finger movements. All PD subjects had unilateral motor symptoms at baseline, but developed bilateral symptoms at follow-up. Within-group analyses were performed by comparing fMRI activation patterns between baseline and follow-up scans. Between-group comparisons were made by contrasting fMRI activation patterns generated by the more-affected and less-affected hands of PD subjects with the mean of the dominant and non-dominant hands of Controls. Compared to baseline, Controls showed changes in CTC circuits, but PD subjects had increased recruitment of both cortical motor-associated and cerebellar areas. Compared to Controls, PD subjects demonstrated augmented recruitment of CTC circuits over time that was statistically significant when the IG task was performed by the hand that transitioned from non-symptomatic to symptomatic. This longitudinal fMRI study demonstrates increased recruitment of the CTC motor circuit concomitant with PD progression, suggesting a role of the CTC circuit in accommodation to, or pathophysiology of, PD.

Hand coordination as a quantitative measure of motor abnormality and therapeutic response in Parkinson's disease

OBJECTIVE

The precision grip-and-lift task (PGLT) has been used to measure hand motor coordination in PD. We designed this study to investigate if the PGLT outcome variables correlate with the UPDRS motor scores and if all PGLT outcome variables are "responsive" to levodopa.

METHODS

We used PGLT to assess hand motor coordination in 10 PD and 10 normal controls before and after levodopa.

RESULTS

Factor analysis showed that the six PGLT parameters were reduced to two factors, a levodopa-responsive factor and a dopa-resistant factor that explained 74% of the total variance. The levodopa-responsive factor, which correlated significantly with "off" UPDRS motor scores, includes load preparation time, maximum vertical acceleration, maximum grip velocity and maximum grip force. The levodopa-resistant factor, which did not correlate with "off" UPDRS motor scores, included maximum negative load force and tremor during lift. Both dopa-responsive and dopa-resistant factors were altered in PD compared to controls before levodopa. Levodopa improved dopa-responsive, but not dopa-resistant factor in PD.

CONCLUSIONS

PGLT can measure two aspects of fine motor performance, both affected by PD but differentially affected by levodopa.

SIGNIFICANCE

PGLT can be useful in characterizing the response of motor abnormality in PD therapeutic trials.

Task specific influences of Parkinson's disease on the striato-thalamo-cortical and cerebello-thalamo-cortical motor circuitries

The motor deficits in Parkinson's disease (PD) have been primarily associated with internally guided (IG), but not externally guided (EG), tasks. This study investigated the functional mechanisms underlying this phenomenon using genetically-matched twins. Functional magnetic resonance images were obtained from a monozygotic twin pair discordant for clinical PD. Single-photon emission computed tomography neuroimaging using [(123)I](-)-2-beta-carboxymethoxy-3-beta-(4-iodophenyl)tropane confirmed their disease-discordant status by demonstrating a severe loss of transporter binding in the PD-twin, whereas the non-PD-twin was normal. Six runs of functional magnetic resonance imaging (fMRI) data were acquired from each twin performing EG and IG right-hand finger sequential tasks. The percentage of voxels activated in each of several regions of interest (ROI) was calculated. Multiple analysis of variance was used to compare each twin's activity in ROIs constituting the striato-thalamo-cortical motor circuits [basal ganglia (BG)-cortical circuitry, but including the globus pallidus/putamen, thalamus, supplementary motor area, and primary motor cortex] and cerebello-thalamo-cortical circuits (cerebellar-cortical circuitry, including the cerebellum, thalamus, somatosensory cortex, and lateral premotor cortex). During the EG task, there were no significant differences between the twins in bilateral BG-cortical pathways, either basally or after levodopa, whereas the PD-twin had relatively increased activity in the cerebellar-cortical pathways basally that was normalized by levodopa. During the IG task, the PD-twin had less activation than the non-PD-twin in ROIs of the bilateral BG-cortical and cerebellar-cortical pathways. Levodopa normalized the hypoactivation in the contralateral BG-cortical pathway, but "over-corrected" the activation in the ipsilateral BG-cortical and bilateral cerebellar-cortical pathways. In this first fMRI study of twins discordant for PD, the data support the hypothesis that BG-cortical and cerebellar-cortical pathways are task-specifically influenced by PD. The levodopa-induced "over-activation" of BG-cortical and cerebellar-cortical pathways, and its relevance to both compensatory changes in PD and the long-term effects of levodopa in PD, merit further exploration.