Bereitschaftspotential in tardive dyskinesia

Dystonia, chorea, hemiballismus and other dyskinesias

Hyperkinesias are heterogeneous involuntary movements that significantly differ in terms of clinical and semeiological manifestations, including rhythm, regularity, speed, duration, and other factors that determine their appearance or suppression. Hyperkinesias are due to complex, variable, and largely undefined pathophysiological mechanisms that may involve different brain areas. In this chapter, we specifically focus on dystonia, chorea and hemiballismus, and other dyskinesias, specifically, levodopa-induced, tardive, and cranial dyskinesia. We address the role of neurophysiological studies aimed at explaining the pathophysiology of these conditions. We mainly refer to human studies using surface and invasive in-depth recordings, as well as spinal, brainstem, and transcortical reflexology and non-invasive brain stimulation techniques. We discuss the extent to which the neurophysiological abnormalities observed in hyperkinesias may be explained by pathophysiological models. We highlight the most relevant issues that deserve future research efforts. The potential role of neurophysiological assessment in the clinical context of hyperkinesia is also discussed.

Willed action and its impairments

Actions are goal-directed behaviours that usually involve movem ent. There is evidence that intentional self-generated actions (willed actions) are controlled differently from routine, stereotyped actions that are externally triggered by environmental stimuli. We review evidence from investigations using positron emission tomography (PET), recordings of movement-related cortical potentials (MRCPs) or transcranial magnetic stimulation (TMS), and conclude that willed actions are controlled by a network of frontal cortical (dorsolateral prefrontal cortex, supplementary motor area, anterior cingulate) and subcortical (thalamus and basal ganglia) areas. We also consider evidence suggesting that some of the cognitive and motor deficits of patients with frontal lesions, Parkinson's disease, or schizophrenia as well as apathy and abulia and rarer phenomena such as primary obsessional slowness can be considered as reflecting im pairment of willed actions. We propose that the concept of a willed action system based on the frontostriatal circuits provides a useful framework for integrating the cognitive, motor, and motivational deficits found in these disorders. Problems remaining to be resolved include: identification of the component processes of willed actions; the specific and differential role played by each of the frontal cortical and subcortical areas in the control of willed actions; the specific mechanisms of impairm ent of willed actions in Parkinson's disease, schizophrenia, and frontal damage; and the precise role of the neurotransmitter dopamine in the willed action system.

Which perspectives can endophenotypes and biological markers offer in the early recognition of schizophrenia?

The early recognition of schizophrenia seems crucial; various studies relate a longer duration-of-untreated-psychosis to a worse prognosis. We give an overview over common psychopathological early recognition instruments (BSABS, CAARMS, SIPS, IRAOS, ERIraos). However, many clinical symptoms of prodromal schizophrenia stages are not sufficiently specific. Thus we review recent contributions of neuroimaging and electrophysiological as well as genetic studies: which new diagnostic perspectives offer endophenotypes (such as P300, P50 sensory gating, MMN, smooth pursuit eye movements; indicating a specific genetic vulnerability) together with a better understanding of schizophrenic pathophysiology (state-dependent biological markers, e.g. aggravated motor neurological soft signs during psychosis) in prodromal schizophrenia when still ambiguous clinical symptoms are present. Several examples (e.g. from COMT polymorphisms to working memory deficits) illustrate more specific underlying neuronal mechanisms behind behavioural symptoms. This way, a characteristic pattern of disturbed cerebral maturation might be distinguished in order to complement clinical instruments of early schizophrenia detection.

Neurophysiological investigations in restless legs syndrome and other disorders of movement during sleep

Besides polysomnographic techniques, other neurophysiological methods have been utilized in order to understand the pathophysiology of restless legs and periodic limb movement syndromes. By using electromyography with nerve conduction velocity (EMG-CV) and somatosensory evoked potentials (SEPs) it has been possible to determine how frequently each muscle was involved in periodic limb movements, how frequently EMG activity started in a given muscle and the time delay and pattern of activation between the first and the other activated muscles. The etiology of symptoms does not involve structural lesions since brainstem and spinal pathways are intact. Recent evidence from paired transcranial magnetic stimulation suggests that the pathophysiological key in sleep motor disorders is a modified global excitability of corticospinal pathways. The next neurophysiological goal will be to localize the unresolved anatomical level of sleep disorder movement generators and to describe their mechanism.

Dyskinesia: L-dopa-induced and tardive dyskinesia

Neuroleptic induced tardive dyskinesia and L-dopa-induced dyskinesia are the two most common types of drug-induced abnormal involuntary movements. These two drug-induced dyskinesias are clearly different with respect to the offending drugs and the underlying disease, but they both share a number of intriguing similarities in terms of clinical phenomenology, epidemiology, risk factors, pathophysiological mechanisms and therapeutic responses. In both instances, it is believed that some dysregulation occurring at the level of the striatal dopaminergic receptors, and related non-dopaminergic neurotransmitters systems are playing a crucial role in the development and persistence of the mechanisms causing dyskinesia. These long-lasting functional changes, known as the "priming" phenomenon, are responsible for an impaired balance within the relays of the cortico-subcortical motor loops that release an inadequate output from the basal ganglia leading to an abnormal motor behavior. From a therapeutic perspective, there are also many similarities in the strategies proposed to manage these two dyskinesias. In both cases, unprimed patients not previously exposed to the offending drugs, are offered alternative medications to reduce, at least partly, the risk of occurrence of future dyskinesia: "atypical" neuroleptics in the place of "typical" neuroleptics, and dopamine agonists in the place of L-dopa. In both cases, once dyskinesias are present, in already "primed" patients, both types of dyskinesia appear to be poorly and only partly reversible. Based on limited clinical evidence, it is a common proposal to switch the dyskinetic subject from "typical" to "atypical" neuroleptics for tardive dyskinesia, or to switch from (or more pragmatically to substitute as much as possible) L-dopa to a dopamine agonist for L-dopa-induced dyskinesia. In both cases, efficacious symptomatic antidyskinetic interventions, to reduce the severity of a ready present dyskinesia, are rare. There are some uncontrolled data suggesting that dopamine depleting agents, like tetrabenazine, are possibly useful for tardive dyskinesia; however, there is more clinical evidence to support the efficacy of amantadine and functional surgery in parkinsonian patients with L-dopa-induced dyskinesia.

Delayed onset of late movement-related cortical potentials and abnormal response to lorazepam in catatonia

Catatonia is a psychomotor syndrome with an inability to execute and terminate movements completely, leading consecutively to akinesia and posturing, which both respond almost immediately to benzodiazepines, i.e. gaba-potentiators like lorazepam. However, pathophysiological mechanisms of cortical motor and gaba-ergic dysfunction remain unclear. We therefore investigated movement-related cortical potentials (MRPs) and movement kinematics during a motor task before and after lorazepam. Ten akinetic catatonic patients were compared with 10 psychiatric (similar age, sex, medication, and underlying psychiatric disease but without catatonic syndrome) and 20 healthy controls. MRPs from frontal (F), central (C), and parietal (P) sites were recorded to obtain measures of early and late readiness potential and movement potential. Kinematic measures included parameters for amplitude of movements, peak velocity, average duration of movements, elevation angle, and angle velocity. The motor task consisted in self-initiated extension of the right index finger. All catatonic and psychiatric control patients received intravenous lorazepam (1mg), whereas healthy controls were subjected to a placebo-controlled (10 received lorazepam, 10 received placebo) double-blind study design.Catatonics showed a significantly delayed onset of late readiness and movement potential in central electrodes (Cz, C3) compared with psychiatric and healthy controls. This delayed onset correlated significantly with catatonic motor symptoms and movement duration. Lorazepam led to significantly stronger delays in onset of late readiness potential in left fronto-parietal (F3, C3, P3) electrodes in catatonic patients than in psychiatric and healthy controls. It is concluded that delayed latencies in late MRP components in catatonic patients may reflect their inability to execute and terminate movements completely. Differential and stronger response to lorazepam in catatonia suggests dysfunction in inhibitory control of cortical motor function with increased gaba-ergic sensitivity.

The abnormality of N30 somatosensory evoked potential in idiopathic Parkinson's disease is unrelated to disease stage or clinical scores and insensitive to dopamine manipulations

We recorded short latency somatosensory evoked potentials (SEPs) to median nerve stimuli in 40 patients affected by idiopathic Parkinson's disease (PD) classified from I to IV on the Hoehn and Yahr disability scale. SEPs were recorded before and after chronic administration of L-Dopa and bromocriptine, before and after acute administration of L-Dopa. Fourteen patients experiencing wearing off and dystonic-dyskinetic disturbances were recorded during the occurrence of these oscillations of their clinical status. Absent or reduced N30 components were found in 32.5% of patients. SEPs were not modified by acute or chronic administration of L-Dopa or bromocriptine or during off and dystonic or dyskinetic conditions. Multiple correlations of N30 with scores of the Unified Parkinson's Disease Rating Scale showed that N30 abnormality did not classify patients with prominent clinical features, nor did it predict the outcome of treatment.

Intracerebral recording of movement related readiness potentials: an exploration in epileptic patients

Readiness potentials (RPs) preceding voluntary self-paced limb movements were recorded intracerebrally in 13 patients suffering drug resistant, intractable epilepsy. Multilead depth electrodes were positioned using the Talairach's coordinate system; they allowed simultaneous recording from the external and mesial cortices and from the interposed white matter during self-paced unilateral hand or plantar flexions. Our intracerebral explorations have shown RPs in the primary motor cortex (MC) contralateral to the movement and in both supplementary motor areas (SMAs), indicating that at least 3 cortical sites become active before the movement. At variance with the scalp RPs recorded in the same patients, the intracerebral potentials were either negative, or positive, depending on the recording site. No consistent differences in duration and time of onset could be established between the MC and the SMA RPs, at least with the used time resolution. RPs were only occasionally observed in the parietal cortex and hippocampus and none were recorded from the amygdala, the temporal, temporo-occipital, prefrontal, frontal and cingular cortices. The wide topographical distribution of the scalp RPs may not be fully explained by the above intracortical findings, leaving the possibility that other generators exist, whose locations remain to be determined.

Bereitschaftspotential: is there a contribution of the supplementary motor area?

Bereitschaftspotentials (BPs) preceding simple repetitive finger movements were recorded in 11 normal volunteers. By modeling the recorded data with multiple equivalent dipoles we found that bilateral sources in the motor cortex were the best fitting hypothesis for the early BP. The activity of the source contralateral to the moving finger was increased during the steep slope of the late BP before and during the motor potential. Around and after electromyogram (EMG) onset, separate sources were detected for the motor potential close to the anterior wall of the central sulcus, and for the reafferent somatosensory potential in the postcentral gyrus. Their source wave forms showed short transient deflections peaking about 10 msec and 100 msec, respectively, after EMG onset. No evidence was found for significant source currents in the supplementary motor area (SMA), which has been suggested as the main generator of the BP. Placing probe dipoles arbitrarily into the region of the SMA did not result in the detection of a large source activity. Therefore, we conclude that the SMA does not provide a major contribution to the scalp BP during simple repetitive finger movements.

Neural networks and Parkinson's disease

A closed-loop or recurrent neural network was taught to generate output discharges to reproduce the prototypical activations in agonist and antagonist muscles which produce the displacement of a limb about a single joint. By introducing a generalized decrease in the excitability of the pre-output layer in the network, the network made the displacement more slowly and also showed an inability to maintain a repetitive movement. These concepts can be applied to the human nervous system in the understanding of the physical basis of movement and its disorders. It is suggested that a movement represents the output of a closed-loop network, such as the cortical-basal ganglia-thalamic-cortical motor loop, which iterates repetitively to its end point or attractor. The model provides an explanation of how the state of thalamic inhibition seen in Parkinson's disease physically may produce bradykinesia and the inability to maintain a repetitive movement.

Bereitschaftspotential in idiopathic and symptomatic restless legs syndrome

Patients with idiopathic and symptomatic restless legs syndrome (RLS) suffer from "dyskinesia while awake" or "daytime myoclonus" when at rest preceded by sensory symptoms. In order to characterise the RLS either as reflex movement or as voluntary movement we measured movement-related cortical potentials in 5 idiopathic and 8 uraemic RLS patients. Movements from both legs were polygraphically recorded concomitantly with cortical activity 2000 msec before to 500 msec after onset of EMG activity. These data were compared with a voluntary simulation of each patient's movement pattern and with 5 age-matched controls performing dorsiflexion of the right, left and both feet. Cortical activity preceding daytime myoclonus was absent in RLS patients whereas self-initiated leg movements in patients elicited onset times (1180-1380 msec) and amplitudes of Bereitschaftspotential (readiness potential) not significantly different from readiness potentials in control subjects (P > 0.05). Lack of movement-related potentials in myoclonus and/or dyskinesias during daytime in RLS patients is compatible with an involuntary mechanism of induction and points towards a subcortical or spinal origin of RLS.

Role of primate basal ganglia and frontal cortex in the internal generation of movements. III. Neuronal activity in the supplementary motor area

This study is a part of a project investigating neuronal activity in the basal ganglia and frontal cortex and describes externally and internally induced preparatory activity in the supplementary motor area (SMA), which forms a closed neuronal loop with the striatum. Monkeys made self-initiated arm reaching movements toward a constant target in the absence of phasic external stimuli. In separate blocks of trials, animals performed in a delayed go no-go task in which an instruction cue prepared for subsequent movement or no-movement to a trigger stimulus. A total of 328 neurons were tested in the delay task. Of these, 91 responded transiently to the instruction light with a median latency of 262 ms. Three quarters of these responses were restricted to the instruction preparing for arm movement, as opposed to withholding it, and thus may be involved in movement preparation processes. Sustained activation during the instruction-trigger interval was found for 67 neurons and occurred nearly exclusively in movement trials. Activation usually increased gradually after the cue and ended abruptly upon movement onset and thus could be related to the setting and maintenance of processes underlying the preparation of movement. Time-locked responses to the trigger stimulus were found in 38 neurons and were usually restricted to movement trials (median latency 80 ms). Activity time-locked to movement execution occurred in 67 neurons, beginning up to 252 ms before movement onset. A total of 266 neurons were tested with self-initiated arm movements. Of these, 43 showed premovement activity beginning 610-3030 ms before movement onset (median 1430 ms). The activity increased slowly and reached its peak at 370 ms before movement onset. It ended before movement onset or continued until the arm began to move or reached the target. This activity appears to reflect neuronal processes related to the internal generation of movements. Two thirds of activations preceding self-initiated movements occurred in neurons not activated before externally instructed movements, suggesting a selectivity for the internal generation process. Activity related to the execution of self-initiated movements occurred in 67 neurons: it began during and up to 420 ms before movement onset and was usually not associated with premovement activity. Most of these neurons were also activated with stimulus-triggered movements, suggesting a lack of selectivity for the execution of self-initiated movements. In comparison with the striatum, more SMA neurons showed preparatory activity preceding externally instructed movements (transient 27% vs 16%, sustained 20% vs 12%) and self-initiated movements (16% vs 11%).(ABSTRACT TRUNCATED AT 400 WORDS)

Abnormal premovement brain potentials in schizophrenia

We assessed scalp-recorded movement related potentials (MRPs) generated prior to voluntary movements in chronic, medicated schizophrenics (n = 9) and age matched normal controls (n = 9). MRPs were recorded in a self-paced button press task in which subjects pressed a button with either their right, left or both thumbs (experimental condition I, II and III respectively). Controls generated a slowly rising readiness potential (RP) at about 1000 ms, a negative shift (NS') at about 450 ms and a motor potential (MP) at about 100 ms prior to movement. The initial MRP components (RP and NS') were reduced in schizophrenics indicating an impairment of the voluntary preparatory process in schizophrenia. Results of the present study indicate a similarity of MRP findings in schizophrenics and reported MRPs (Singh and Knight, 1990) in patients with unilateral lesions of the dorsolateral prefrontal cortex. These findings provide further support for frontal lobe dysfunction in schizophrenia.

Spectral analysis of EEG during self-paced movements: differences between untreated schizophrenics and normal controls

Thirteen untreated schizophrenic patients, among them nine who had never been treated, were compared with a corresponding number of matched normal controls with regard to changes of the spectral composition of the electroencephalogram (EEG) accompanying voluntary movements. Triggered by self-paced movements of the right fingers (fast fist closure), the spectral composition of three epochs was analyzed: (1) rest (2,5-1,5 sec before movement), (2) movement preparation (last sec before movement onset), and (3) movement execution (1st sec following movement onset). For frequencies above 6 Hz, marked differences between schizophrenics and controls were evident, in particular over the parietal electrodes. Whereas patients exhibited a clear decrease of power density during movement as compared to rest, controls showed only a small decrease (left and mid parietal) or virtually none (only right parietal). Consequently there were significant differences over the right parietal area (P4) between patients and controls in the theta, alpha- and beta-bands with regard to the mean power density and center frequencies of these bands. Also at parietal positions, schizophrenics lacked the enhancement of theta-power during the preparatory epoch that was characteristic for normal controls at all parietal positions. The results are discussed with regard to the well-known disturbances of voluntary motor behavior in schizophrenia.

Cortical activity preceding self-initiated and externally triggered voluntary movement

The cortical electromyogram (EMG) activity, preceding voluntary movements, was recorded in 12 normal subjects in two different situations: first, when movements were self-induced by the subjects by their own will; and second, in response to threshold electrical stimulation of the index finger, a brief flash of a light-emitting diode (LED), and a click. Four types of movements were studied: (a) fast extension of the right wrist, (b) fast supination of the left wrist, (c) either movement depending on the subject's own decision or on which index finger was stimulated, and (d) fast sequential right and left wrist extension. In all subjects, self-initiated movements were preceded by a typical Bereitschaftspotential (BP) starting 1,290 +/- 208 ms before the EMG discharge. When the same movements were triggered by an external clue, there was no BP. The BP was present, although with a shorter duration, when subjects were asked to wait for a brief period after index finger stimulation, before extending the right wrist. From these results, we conclude that the BP is closely associated with the timing of internally generated movements, and that different cortical areas are probably involved in the generation of self-induced and externally referenced movements in humans.