Contingent and non-contingent auditory cueing in Parkinson's disease

Does Cueing Need Attention? A Pilot Study in People with Parkinson's Disease

We previously showed that both open-loop (beat of a metronome) and closed-loop (phase-dependent tactile feedback) cueing may be similarly effective in reducing Freezing of Gait (FoG), assessed with a quantitative FoG Index, while turning in place in the laboratory in a group of people with Parkinson's disease (PD). Despite the similar changes on the FoG Index, it is not known whether both cueing responses require attentional control, which would explain FoG Index improvement. The mechanisms underlying cueing responses are poorly understood. Here, we tested the hypothesis that the salience network would predict responsiveness (i.e., FoG Index improvement) to open-loop and closed-loop cueing in people with and without FoG of PD, as salience network contributes to tasks requiring attention to external stimuli in healthy adults. Thirteen people with PD with high-quality imaging data were analyzed to characterize relationships between resting-state MRI functional connectivity and responses to cues. The interaction of the salience network and retrosplenial-temporal networks was the best predictor of responsiveness to open-loop cueing, presenting the largest effect size (d = 1.16). The interaction between the salience network and subcortical as well as cingulo-parietal and subcortical networks were the strongest predictors of responsiveness to closed-loop cueing, presenting the largest effect sizes (d = 1.06 and d = 0.84, respectively). Salience network activity was a common predictor of responsiveness to both cueing, which suggests that auditory and proprioceptive stimuli during turning may require some level of cognitive and insular activity, anchored within the salience network, which explain FoG Index improvements in people with PD.

How groove in music affects gait

Rhythmic auditory stimulation (RAS) is a gait intervention in which gait-disordered patients synchronise footsteps to music or metronome cues. Musical 'groove', the tendency of music to induce movement, has previously been shown to be associated with faster gait, however, why groove affects gait remains unclear. One mechanism by which groove may affect gait is that of beat salience: music that is higher in groove has more salient musical beats, and higher beat salience might reduce the cognitive demands of perceiving the beat and synchronizing footsteps to it. If groove's effects on gait are driven primarily by the impact of beat salience on cognitive demands, then groove's effects might only be present in contexts in which it is relevant to reduce cognitive demands. Such contexts could include task parameters that increase cognitive demands (such as the requirement to synchronise to the beat), or individual differences that may make synchronisation more cognitively demanding. Here, we examined whether high beat salience can account for the effects of high-groove music on gait. First, we increased the beat salience of low-groove music to be similar to that of high-groove music by embedding metronome beats in low and high-groove music. We examined whether low-groove music with high beat salience elicited similar effects on gait as high-groove music. Second, we examined the effect of removing the requirement to synchronise footsteps to the beat (i.e., allowing participants to walk freely with the music), which is thought to remove the cognitive demand of synchronizing movements to the beat. We tested two populations thought to be sensitive to the cognitive demands of synchronisation, weak beat-perceivers and older adults. We found that increasing the beat salience of low-groove music increased stride velocity, but strides were still slower than with high-groove music. Similarly, removing the requirement to synchronise elicited faster, less variable gait, and reduced bias for stability, but high-groove music still elicited faster strides than low-groove music. These findings suggest that beat salience contributes to groove's effect on gait, but it does not fully account for it. Despite reducing task difficulty by equalizing beat salience and removing the requirement to synchronise, high-groove music still elicited faster, less variable gait. Therefore, other properties of groove also appear to play a role in groove's effect on gait.

Can Rehabilitation Influence the Efficiency of Control Signals in Complex Motion Strategies?

The factor determining quality of life in Parkinson's disease (PD) is the worsening of a patient's walking ability. The use of external stimuli can improve gait when performing complex motor patterns. The aim of this study was to evaluate the effect of rehabilitation on the effectiveness of control signals in people with PD. The study was performed on 42 people with idiopathic PD in the third stage of disease. The control group consisted of 19 patients who did not participate in rehabilitation activities. The experimental group was systematically participating in rehabilitation activities twice a week (60 minutes) for 9 months. Gait speed, mean step length, and step frequency were calculated on the basis of the obtained results. These parameters were compared in both groups by single factor variance analyses. The best results were obtained using rhythmic external auditory signals. The group with patients actively participating in rehabilitation showed statistically significant improvement in gait speed (12.35%), mean step length (18.00%), and frequency step (2.40%) compared to the control group. The presented research showed the positive effect of rehabilitation and was based on the performance of complex motion patterns, using external control signals for their effectiveness in new motion tasks.

[Visual cues as a therapeutic tool in Parkinson's disease. A systematic review]

Sensory stimuli or sensory cues are being used as a therapeutic tool for improving gait disorders in Parkinson's disease patients, but most studies seem to focus on auditory stimuli. The aim of this study was to conduct a systematic review regarding the use of visual cues over gait disorders, dual tasks during gait, freezing and the incidence of falls in patients with Parkinson to obtain therapeutic implications. We conducted a systematic review in main databases such as Cochrane Database of Systematic Reviews, TripDataBase, PubMed, Ovid MEDLINE, Ovid EMBASE and Physiotherapy Evidence Database, during 2005 to 2012, according to the recommendations of the Consolidated Standards of Reporting Trials, evaluating the quality of the papers included with the Downs & Black Quality Index. 21 articles were finally included in this systematic review (with a total of 892 participants) with variable methodological quality, achieving an average of 17.27 points in the Downs and Black Quality Index (range: 11-21). Visual cues produce improvements over temporal-spatial parameters in gait, turning execution, reducing the appearance of freezing and falls in Parkinson's disease patients. Visual cues appear to benefit dual tasks during gait, reducing the interference of the second task. Further studies are needed to determine the preferred type of stimuli for each stage of the disease.

Effects of cortical and striatal dopamine D1 receptor blockade on cued versus noncued behavioral responses

Various lines of evidence suggest that disruptions in brain dopamine (DA) transmission produce behavioral impairments that can be overcome by salient response-eliciting environmental stimuli. We examined here whether D1 receptor blockade within striatal or frontal cortical DA target regions would differentially affect head entry responses elicited by an auditory cue compared with those occurring during noncued intertrial intervals. Rats received 2 drug-free 28-trial daily sessions in which an auditory cue was immediately followed by food delivery. On the following day, separate groups of rats received bilateral infusions of D1 antagonist SCH23390 to the dorsomedial striatum (DMS), nucleus accumbens (NAcc) core, or the medial prefrontal cortex (mPFC). SCH23390 infused into the DMS and NAcc core suppressed noncued head entries but had no effect on head entries in response to the auditory cue. SCH23390 infused to the mPFC did not reduce either cued or noncued approach responses. Systemic administration of the drug, in contrast, reduced the frequency of both cued and noncued approaches. The results are consistent with the notion that has emerged from the Parkinson's literature that reduced DA transmission produces behavioral suppression that can be overcome by salient environmental response elicitors, and extends this notion by showing that D1 receptor transmission within the striatum strongly suppresses noncued responses while leaving the identical behavior intact when cued by an environmental stimulus.

Biased wrist and finger coordination in Parkinsonian patients during performance of graphical tasks

Handwriting impairments in Parkinson's disease (PD) have been associated with micrographia, i.e. diminished letter size. However, dyscoordination of the wrist and fingers may also contribute to handwriting deterioration in PD. To investigate this hypothesis, right-handed PD patients and controls were tested in performance of three types of cyclic wrist and finger movements: drawing of two lines and a circle. The line drawing was performed with either simultaneous flexion and extension of the wrist and fingers (equivalent pattern resulting in a right-tilted line) or with wrist flexion/extension accompanied with finger extension/flexion (nonequivalent pattern resulting in a left-tilted line). Circle drawing required a specific phase difference between wrist and finger motions. Movements were performed with an inkless pen on a digitizer-tablet at two frequency levels. Consistent deformations of the circle into right-tilted ovals and lower variability in equivalent compared with nonequivalent lines revealed preference to produce right-tilted shapes. This preference became more apparent with increased movement speed and it was amplified in PD patients. Analysis revealed that the circle deformation emerged mainly due to reduction in relative phase, while wrist and finger amplitudes remained unchanged. The results suggest that PD causes deficit characterized by strong tendency to produce certain coordination patterns between wrist and finger motions. This deficit may significantly contribute to handwriting impairments in PD by reducing the dexterity in the production of the variety of shapes of the cursive letters. Furthermore, the deficiency revealed in wrist and finger coordination may represent a more general deficit affecting control of various multi-joint movements in PD.

The attentional cost of external rhythmical cues and their impact on gait in Parkinson's disease: effect of cue modality and task complexity

Changes in gait performance in 153 subjects with PD using three rhythmical cues (auditory, visual and somatosensory) were measured during a simple walking task and a dual walking task in the home. Subjects were 'on' medication and were cued at preferred step frequency. Accelerometers recorded gait and walking speed, step amplitude and step frequency were determined from raw data. Data were analysed with SAS using linear regression models. Gait performance during a single task reduced with cues in contrast to a dual task where PD subjects appeared to benefit from rhythmical cues (increased speed and step length). Effects were dependent on cue modality with significant improvements for auditory cues compared to others. A significant short-term carry-over effect of cues reduced 3 weeks later. Cues may reduce attentional demands by facilitating attentional allocation, accounting for differences of cue seen during single and dual task. Furthermore cue modality may influence attentional demand which is an important consideration for rehabilitation.

The effect of viewing graspable objects and actions in Parkinson's disease

Viewing action-relevant stimuli such as a graspable object or another person moving can affect the observer's own motor system. Evidence exists that external stimuli may facilitate or hinder movement in Parkinson's disease, so we investigated whether action-relevant stimuli would exert a stronger influence. We measured the effect of action-relevant stimuli (graspable door handles and finger movements) on reaction times compared with baseline stimuli (bars and object movements). Parkinson's patients were influenced by the location of the baseline stimuli, but unlike healthy controls, action-relevant stimuli did not exert a stronger influence. This suggests that external cues exert their influence in Parkinson's disease through lower-level visual processes and the influence of action-relevant stimuli on the motor system is disrupted.

Contribution of the frontal lobe to externally and internally specified verbal responses: fMRI evidence

It has been suggested that within the frontal cortex there is a lateral to medial shift in the control of action, with the lateral premotor area (PMA) involved in externally specified actions and the medial supplementary motor areas (SMA) involved in internally specified actions. Recent brain imaging studies demonstrate, however, that the control of externally and internally specified actions may involve more complex and overlapping networks involving not only the PMA and the SMA, but also the pre-SMA and the lateral prefrontal cortex (PFC). The aim of the present study was to determine whether these frontal regions are differentially involved in the production of verbal responses, when they are externally specified and when they are internally specified. Participants engaged in three overt speaking tasks in which the degree of response specification differed. The tasks involved reading aloud words (externally specified), or generating words aloud from narrow or broad semantic categories (internally specified). Using fMRI, the location and magnitude of the BOLD activity for these tasks was measured in a group of ten participants. Compared with rest, all tasks activated the primary motor area and the SMA-proper, reflecting their common role in speech production. The magnitude of the activity in the PFC (Brodmann area 45), the left PMAv and the pre-SMA increased for word generation, suggesting that each of these three regions plays a role in internally specified action selection. This confirms previous reports concerning the participation of the pre-SMA in verbal response selection. The pattern of activity in PMAv suggests participation in both externally and internally specified verbal actions.

Objective evaluation of manual performance deficits in neurological movement disorders

Impaired hand function is a frequent finding in movement disorders. The skilled control of prehensile finger forces is an essential feature of tool use in daily life. In healthy subjects, grip force is precisely adjusted to the mechanical object properties, such as weight and surface friction. Grip force is accurately scaled to be only a small amount higher than the minimum necessary to prevent a hand-held object from slipping. When an object is lifted and moved around in space, grip force is modulated in parallel with the movement-induced fluctuations in load. The absence of a temporal delay between grip and load force profiles implies that the central nervous system is able to predict the load variations before the intended manipulation. Sensory information is used to adjust the level of applied finger forces efficiently to the requirements of the mechanical object properties and the task at hand. The characteristics of impaired finger force control include inefficient grip force scaling and imprecision of the temporal coupling between grip and load force profiles. Here, we review the characteristics of deficient grip force behavior in movement disorders, e.g. Parkinson's disease, task-specific dystonia, Gille de la Tourette's syndrome and cerebellar disease. Grip force analysis is a highly sensitive method to document even subtle impairments of finger force control and may be used both as a diagnostic tool and for the objective evaluation of treatment in neurological movement disorders.

Evaluation of the effect of training using auditory stimulation on rhythmic movement in Parkinsonian patients—a combined motor and [18F]-FDG PET study

INTRODUCTION

A programme of rehabilitation using auditory cues has previously been shown to decrease movement variability in the gait of Parkinsonian patients.

OBJECTIVE AND METHODS

We studied the temporal variability of finger-tapping and gait in 9 patients with Parkinson's disease (PD) before and after they undertook a physical rehabilitation programme. Positron Emission Tomography (PET) using 2-deoxy-2[(18)F]fluoro-D-glucose (FDG) was performed in these subjects to look for changes in metabolic brain activity after completion of the rehabilitation program.

RESULTS

The reduction of variability was seen not only in gait but also other repetitive movements such as finger tapping. Furthermore, here we show differences in resting regional cerebral glucose utilisation in these patients compared to healthy controls (significant hypometabolism-p < 0.001-for the PD group in the right parietal and temporal lobes, left temporal and frontal lobes and a hypermetabolism in the left cerebellum) and specific changes following the improvements in repetitive movement abilities (significant metabolic increment-p < 0.001-in the PD group in the right cerebellum and in the right parietal and temporal lobes).

CONCLUSIONS

Although our study does not allow us to draw firm conclusions, it provides new information on the neural basis of auditory stimulation in PD. Our results extend those from previous studies to show improvement in the temporal variability of two types of rhythmic movements after participation by PD patients in a physical rehabilitation programme, along with changes in glucose uptake in several brain areas involved in sensorimotor processing.

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

Five parkinsonian subjects with chronic bilateral stimulation of the subthalamic nucleus and five sex- and age-matched healthy controls grasped, lifted, and held an instrumented object. The grip-lift task was either performed at self-determined speed or in response to an auditory cuing signal. Parkinsonian subjects performed the task with subthalamic nucleus stimulation switched ON and OFF. In Parkinson's disease, stimulation of the subthalamic nucleus and the presentation of auditory timing cues improved akinesia of both the grasp and lift components of the task. The finding that auditory timing cues improve akinesia in the absence of subthalamic nucleus stimulation suggests that the basal ganglia are less involved in the control of movements made in response to environmental cues. However, subthalamic nucleus stimulation caused parkinsonian subjects to apply excessive grip forces, regardless of whether the movement was made under self-determined or externally guided speed conditions. This implies that subthalamic nucleus stimulation produces a generalized upregulation in the gain of all components of a movement without the subtlety of focused control that is required to normalize performance.

Antiparkinson medications improve agonist activation but not antagonist inhibition during sequential reaching movements

The execution of sequential arm movements is critical to activities of daily living such as eating and grooming. It is known that movement sequences are bradykinetic in people with Parkinson's disease (PD) and that antiparkinson medications improve the speed of movement sequences. However, it is unclear how muscle activity is modulated during sequential movements and what effect antiparkinson medications have on muscle modulation. We studied subjects with PD and age- and gender-matched control subjects making sequential reaching movements. Subjects with PD were tested before and after their morning dose of antiparkinson medications (levodopa and/or dopamine agonists). We examined the effect of antiparkinson medications on the modulation of muscle activity (i.e., the ability to activate and inhibit each muscle throughout the course of a sequence). Results showed that the group with PD, before medication, moved more slowly and modulated muscle activity poorly compared to the control group. Antiparkinson medications improved movement speed as expected, although sequential movements remained slower than normal even after medication. Medication improved the ability to activate agonist muscle activity but did not improve the ability to inhibit antagonist activity. Instead, antagonist activity was also increased, resulting in minimal improvements in muscle modulation during sequential reaching movements.

The effect of external rhythmic cues (auditory and visual) on walking during a functional task in homes of people with Parkinson's disease

OBJECTIVES

To evaluate (1) the influence of rhythmic cues on gait interference during a functional activity and (2) the relationship of clinical symptoms to gait interference.

DESIGN

Repeated-measures study.

SETTING

Participants' homes.

PARTICIPANTS

Twenty subjects with idiopathic Parkinson's disease (PD) and a control group of 10 age-, sex-, and education-matched subjects.

INTERVENTIONS

Subjects performed a simple functional task that included a walking component and a dual-motor task. The functional task was performed with and without external rhythmic (auditory and visual) cues.

MAIN OUTCOME MEASURES

Walking speed, mean step length, and step frequency were compared during trials of the tasks. In addition, tests of cognitive executive function (Hayling and Brixton tests), anxiety and depression (Hospital Anxiety and Depression Scale), and fatigue (Multidimensional Fatigue Inventory) were undertaken.

RESULTS

The use of auditory cues during a dual task involving gait reduced the interference effect on the task; significant increases in step length were observed in PD subjects ( P =.018), representing an increase of 19%.

CONCLUSIONS

External auditory cues may be useful in reducing interference and maintaining gait performance during more complicated functional activities. Clinical symptoms, such as depression and fatigue, could influence the ability to focus attention and may increase gait interference during the performance of complex tasks, with subsequent implications for functional walking and safety.

Audiovisual cues can enhance sit-to-stand in patients with Parkinson's disease

We investigated whether preparatory signals, in the form of audiovisual cues, could enhance the performance of sit-to-stand (STS) in Parkinson's disease (PD) patients. Fifteen patients and fifteen control subjects similar in age, gender, weight, and height were examined. All subjects were instructed to carry out STS under self-initiated and cue-initiated conditions. A PEAK Motion Analysis System and two force plates were synchronized to record kinematic and kinetic data. In patients with PD, the addition of audiovisual cues was found to increase hip flexion and knee extension torques and decrease the time-to-peak joint torques, as well as increase peak horizontal and vertical velocities of the body center of mass and decrease the time taken to complete STS. Consequently, the performance of STS in these patients approached that of control subjects. In fact, during cue-initiated STS, no difference was found between the patient and control groups for the time-to-peak of all joint torques, the peak horizontal and vertical velocities, and the time taken to complete STS. Our findings thus demonstrated that audiovisual cues were effective in enhancing STS in patients with PD. These feed-forward signals could have enhanced the defective motor preparatory phase, thus leading to improved performance of the STS task. These findings provide a scientific basis for the use of audiovisual signals to enhance STS performance in patients with PD.

Inter-limb coupling in bimanual rhythmic coordination in Parkinson’s disease

Recently, it has been shown that rhythmic inter-limb coordination is disturbed in patients with Parkinson's disease (PD). The present study aims to investigate whether this coordination deficit is primarily the result of an impaired coupling, related to hypoactivation of the supplementary motor area (SMA), or primarily the indirect result of an asymmetrical distribution of PD symptoms over the left and right limbs (a peripheral process). Thirty PD patients and 30 matched control participants tapped with the index fingers anti-phase and left and right leading gallop patterns in four visual feedback conditions. Symmetrically affected participants performed significantly worse than asymmetrically affected and control participants in the gallop patterns. This result suggested that the central deficit has a stronger effect on inter-limb coupling in PD than the neuromuscular and biomechanical asymmetry between the limbs. Detailed analysis of inter-tap intervals (variability and correlation) suggested that this deficit leads to a compensatory asymmetrical inter-limb coupling in the primarily right-affected patient group, and under specific circumstances also in the primarily left-affected patient group. The difference in coordination strategy between left- and right-affected patients suggested that pre-morbid hand preference is an important structural constraint on the coupling strategies available to the participants.

Striatal dopamine and learning strategy-an (123)I-FP-CIT SPECT study

Patients with Parkinson's disease (PD) have difficulty in processing learning tasks that lack external guidelines and, consequently, necessitate the subjects to generate their own problem-solving strategy. While the contribution of striatal dopaminergic deficiency to PD-specific motor symptoms is well established, its role in the PD-characteristic deviant learning style remains unclear. The aim of this study was to assess the relation between striatal dopamine activity as revealed by single photon emission computed tomography (SPECT) with (123)I-FP-CIT, a ligand for the dopamine transporter (DaT), and type of learning strategy, as identified by the California Verbal Learning Task (CVLT) in 19 patients with probable PD. The results showed a robust inverse correlation between striatal dopamine DaT binding and the externally guided, serial learning strategy: the lower the DaT in caudate nucleus as well as in putamen, the more the patient group appeared to rely on externally structured learning. Additionally, a significant positive correlation was found between caudatal DaT activity and the internally generated, semantic learning strategy. Unlike these strategic learning characteristics, IQ equivalent and recall total score appeared to vary independently from striatal DaT availability.

CONCLUSION

our findings provide direct evidence that striatal dopaminergic activity is specifically involved in the regulation of strategic learning processes.

Effects of deep brain stimulation on prehensile movements in PD patients are less pronounced when external timing cues are provided

It has been repeatedly demonstrated that the movements of patients with Parkinson's disease (PD) are less impaired when external timing cues are provided. This suggests that the basal ganglia, which are impaired in PD, are less involved in the control of externally timed movements. In the present study, we tested this hypothesis by contrasting the effect of deep brain stimulation (DBS) in the basal ganglia (more precisely, the internal globus pallidum) on internally versus externally timed movements. Our first movement task was a standard prehensile task involving a reach-to-grasp movement. In the externally-timed condition, the target object was moving rapidly away from the subject; in the internally-timed condition, the target object was stationary. We found, that for most aspects of the prehensile movement the effect of DBS was less pronounced in the externally than in the internally timed condition. A similar reduction of the DBS effects in the externally-timed condition was also found for a second movement task, which required an isolated grasping movement. We conclude that the basal ganglia are significantly less involved in the control of externally timed movements.

Motor sequencing in Parkinson's disease: relationship to executive function and motor rigidity

Parkinson's disease (PD) is a movement disorder that also affects central cognitive processing; however, the extent to which high-order cognitive processes disrupted by PD affect complex motor function is incompletely explicated. The present analysis provides an examination of the relative contributions of simple motor versus complex cognitive functions involving sequencing, problem solving, and overall cognitive status to complex motor movements involving sequencing and temporal ordering in PD. Motor sequencing performance was videotaped for quantitative scoring. Compared with an age-matched control group, the PD group was impaired on motor agility and motor sequencing tasks in addition to cognitive sequencing and set shifting tasks. Neither current cognitive functioning, age, disease duration, nor overall intellectual abilities accounted for the relationships between motor sequencing and cognitive sequencing abilities in PD. By contrast, both sequencing and nonsequencing executive functions predicted motor sequencing performance as well as or better than motor rigidity or overall cognitive status. These relationships were strongest for the most challenging motor sequencing task, fist-edge-palm, and did not apply to the least challenging task, which required simple alternations of hand movements. Unlike PD, controls showed correlations between motor sequencing tests and executive functioning only tapping nonsequencing abilities. Thus, despite the predominant motor feature of PD, executive functions, as assessed by sequencing and set formation, predicted motor sequencing performance as well as or better than simple motor performance. The results further suggest that the more complex the motor sequencing task, the more susceptible it is to influence from generalized cognitive sequencing ability.

Memory performance under varying cueing conditions in patients with Parkinson's disease

The present study is a continuation of a previous study in memory performance which showed that Parkinson's disease (PD) patients increasingly relied on explicit cues which prompt the external strategy of serial clustering, in comparison to control subjects (CS), who profited increasingly from implicit cues which prompt the internal and more effective strategy of semantic clustering. In this study, we investigated whether the recall of PD patients can be affected by adding or removing explicit cues. We manipulated the California Verbal Learning Test in two ways. First, we told the subjects under study in advance from which categories the items to be recalled were derived, thus making the implicit cue to cluster semantically explicit (explicit condition). Next, we permuted the sequence of the items in each trial, thus preventing the subjects from adhering to the serial order, i.e. to explicit cues (permuted condition). We included the data of our previous study (mixed condition) in the analysis of memory and learning performance in the three conditions. Learning of PD patients, as reflected in the semantic ratio, proved to be more affected by the cueing conditions than that of CS. Total performance and the serial ratios did not show a significant interaction between group and cueing condition. The results are discussed in terms of external and internal generation of problem-solving strategies.

The effects of Parkinson's disease on the capacity to generate information randomly

In two experiments, the capacity of Parkinson patients and normal controls to generate letters randomly was investigated using a dual task. The task was based on Baddeley's work (Baddeley, A. D., Quarterly Journal of experimental Psychology 18, 119-129, 1966) where participants vocalize letters of the alphabet in random order. The task was performed under two conditions where letters were (a) vocalized at a specified rate (0.5, 1, 2 and 4 sec); and (B) letters were vocalized at the same rates but with a secondary task of sorting cards into one, two, four and eight categories. The aim was to test the notion of non-specific slowing in response selection processing in Parkinson's disease. Results showed that randomness decreased as generation rate increased in both groups, but with the patient group significantly impaired in comparison to controls. The notion of a limited capacity response selector based on disruption to the Supervisory Attentional System is invoked to account for the impaired capacity of the patient group to generate information internally.