Increased response to visual feedback of drug-induced dyskinetic movements in advanced Parkinson's disease

Remnants of Cardinal Symptoms of Parkinson's Disease, Not Dyskinesia, Are Problematic for Dyskinetic Patients Performing Activities of Daily Living

Introduction: The impact of levodopa-induced dyskinesia (LID) on the daily lives of patients with Parkinson's disease (PD) remains to be determined. Furthermore, evidence suggests that cardinal motor symptoms of PD may coexist with LID, but their impact on activities of daily living (ADL) relative to LID is not known. This cross-sectional study aimed at determining the effect of LID and cardinal motor symptoms of PD on ADL in patients who were experiencing peak-dose choreic-type LID.

Method: One hundred and twenty-one patients diagnosed with PD known to experience choreic-type LID were recruited for the study. Patients were asked to perform a set of ADL. Levels of LID, tremor, bradykinesia, and freezing of gait (FoG) were measured using 17 inertial sensors design to capture full body movements, while rigidity, and postural instability were assessed using clinical evaluations. Cognition was also assessed using the mini-mental state examination. Success criteria were set for each ADL using the time needed to perform the task and errors measured in 69 age-gender-matched healthy controls. Binary logistic regressions were used to identify symptoms influencing success or failure for each activity. Receiver operating characteristic curves were computed on each significant symptom, and Youden indexes were calculated to determine the critical level of symptomatology at which the performance significantly changed.

Results: Results show that 97.7% of patients who presented with LID during the experiment also presented with at least one cardinal motor symptom. On average, patients took more time and did more errors during ADL. Multivariate analyses revealed that for the great majority of ADL, LID were not associated with worsening of performance; however, postural instability, tremor, rigidity, and cognitive decline significantly decreased the odds of success.

Conclusions: Residual symptoms of PD, such as tremor, rigidity, and postural instability still present at peak-dose were more problematic than LID in the performance of ADL for patients experiencing slight-to-moderate LID. We also found that cognitive decline was associated with decreased performance in certain tasks. Therefore, a strategy using lower doses of medication to manage LID may be counterproductive since it would not address most of these symptoms already present in patients.

Excessive Sensitivity to Uncertain Visual Input in L-DOPA-Induced Dyskinesias in Parkinson's Disease: Further Implications for Cerebellar Involvement

When faced with visual uncertainty during motor performance, humans rely more on predictive forward models and proprioception and attribute lesser importance to the ambiguous visual feedback. Though disrupted predictive control is typical of patients with cerebellar disease, sensorimotor deficits associated with the involuntary and often unconscious nature of l-DOPA-induced dyskinesias in Parkinson’s disease (PD) suggests dyskinetic subjects may also demonstrate impaired predictive motor control.

Methods: We investigated the motor performance of 9 dyskinetic and 10 non-dyskinetic PD subjects on and off l-DOPA, and of 10 age-matched control subjects, during a large-amplitude, overlearned, visually guided tracking task. Ambiguous visual feedback was introduced by adding “jitter” to a moving target that followed a Lissajous pattern. Root mean square (RMS) tracking error was calculated, and ANOVA, robust multivariate linear regression, and linear dynamical system analyses were used to determine the contribution of speed and ambiguity to tracking performance.

Results: Increasing target ambiguity and speed contributed significantly more to the RMS error of dyskinetic subjects off medication. l-DOPA improved the RMS tracking performance of both PD groups. At higher speeds, controls and PDs without dyskinesia were able to effectively de-weight ambiguous visual information.

Conclusion: PDs’ visually guided motor performance degrades with visual jitter and speed of movement to a greater degree compared to age-matched controls. However, there are fundamental differences in PDs with and without dyskinesia: subjects without dyskinesia are generally slow, and less responsive to dynamic changes in motor task requirements, but in PDs with dyskinesia, there was a trade-off between overall performance and inappropriate reliance on ambiguous visual feedback. This is likely associated with functional changes in posterior parietal–ponto–cerebellar pathways.

Higher iron in the red nucleus marks Parkinson's dyskinesia

Dopamine cell loss and increased iron in the substantia nigra (SN) characterize Parkinson's disease (PD), with cerebellar involvement increasingly recognized, particularly in motor compensation and levodopa-induced dyskinesia (LID) development. Because the red nucleus (RN) mediates cerebellar circuitry, we hypothesized that RN iron changes might reflect cerebellum-related compensation, and/or the intrinsic capacity for LID development. We acquired high resolution magnetic resonance images from 23 control and 38 PD subjects (12 with PD and history of LID [PD+DYS]) and 26 with PD and no history of LID (PD-DYS). Iron content was estimated from bilateral RN and SN transverse relaxation rates (R2*). PD subjects overall displayed higher R2* values in both the SN and RN. RN R2* values correlated with off-drug Unified Parkinson's Disease Rating Scale-motor scores, but not disease duration or drug dosage. RN R2* values were significantly higher in PD+DYS compared with control and PD-DYS subjects; control and PD-DYS subjects did not differ. The association of higher RN iron content with PD-related dyskinesia suggests increased iron content is involved in, or reflects, greater cerebellar compensatory capacity and thus increased likelihood of LID development.

Assessing manual pursuit tracking in Parkinson's disease via linear dynamical systems

Quantitative assessment of motor performance is important for diseases of motor control, such as Parkinson's disease (PD). Manual tracking tasks are well suited for motor assessment, as they can be performed concomitantly with brain mapping techniques. Here we propose utilizing second-order linear dynamical systems to assess manual pursuit tracking performance. With the desired trajectory as the input, and the subject's actual motor response as the output, a linear model characterized by natural frequency and damping ratio is identified for each subject. We applied this method to 10 PD subjects (on and off L: -dopa medication) and 10 normal subjects performing a multi-frequency sinusoidal tracking task. Model parameters were more sensitive than overall tracking errors in determining significant differences between groups. The effect of L: -dopa medication was to reduce the damping ratio and make the range in natural frequency across individuals approach that of normal subjects. We interpret the changes in damping ratio and natural frequency as possibly related to suppression of compensatory cerebellar activity and/or improvement of motor program selection, and the changes in natural frequency as an implicit strategy to maintain settling time in the face of reduce damping ratio. Our results suggest that simple linear dynamical system models can be a powerful method to assess tracking performance in Parkinson's disease because of the additional insight they can provide into neurological processes.

Movement patterns of peak-dose levodopa-induced dyskinesias in patients with Parkinson's disease

The present study characterized involuntary movements associated with levodopa-induced dyskinesias (LID) in patients with Parkinson's disease. We used amplitude, proportional energy, frequency dispersion and sample entropy to determine whether LID movement patterns are truly random, as clinical description seems to suggest, or possess some underlying pattern that is not visible to the naked eye. LID was captured using a magnetic tracker system, which provided 3D rendering of whole-body LID. Patients were instructed to maintain a standing position, with arms extended in front of them. We compared the measurements of the dyskinetic PD group (DPD) with 10 patients without dyskinesias (NDPD) and 10 control subjects. In comparison to the other two groups, movement patterns from the DPD group had significantly higher amplitude, confirming the presence of dyskinesias. In addition, higher frequency components in the power spectrum of velocity were detected, suggestive of higher velocity in LID movement. Furthermore, there was a concentration in narrow frequency bands, which suggested stable oscillatory activity. Finally, sample entropy revealed more regularity in the DPD group. Although not statistically significant, we found that the amplitude from the NDPD group had a tendency to be smaller than those of controls. As well, the spectra were often more dispersed for the NDPD group. In conclusion, the present results suggest that LID cannot be considered as purely random movement since they possess some deterministic pattern of motion. This may provide a way for patients to adapt to these involuntary movements while performing voluntary motor acts.

The influence of levodopa-induced dyskinesias on manual tracking in patients with Parkinson’s disease

The influence of peak-dose, levodopa-induced dyskinesias (LID) on manual tracking (MT) was examined in 10 dyskinetic patients with Parkinson's disease (DPD), and compared to 10 age/gender-matched non-dyskinetic patients with Parkinson's disease (NDPD) and 10 healthy controls. Whole-body movement (WBM) and MT performance were recorded simultaneously with a 6-degrees-of-freedom magnetic motion tracker and forearm rotation sensors, respectively. Subjects were asked to match the length of a computer-generated line with a line they controlled via wrist rotation. Results show that DPD patients had greater WBM magnitude at rest and during the motor task, both in displacement and in velocity. All groups displayed some increase in WBM displacement from rest to MT, but only the DPD group had a significant increase in WBM velocity during movement. As for MT performance (determined by assessing the positional mismatch between subjects' and target lines), ERROR in displacement was statistically similar between groups. There was no correlation between ERROR and the magnitude of WBM within the DPD group. The DPD group showed significant increased ERROR when the velocity of the subject's line was compared with that of the velocity of the target line. When two distinct target pace segments were examined (FAST/SLOW), no significant differences were found in ERROR for displacement for either group, but both the NDPD and DPD group showed increased ERROR from SLOW to FAST for velocity. This was accompanied with an increase in WBM velocity only in the DPD group. The lack of increased ERROR during the SLOW tracking portion in the DPD group supports the notion that the dyskinesias themselves were not primarily responsible for the ERROR seen in the patients. When examining the positive or negative values of ERROR (i.e., faster or slower than the target), we found that the increased ERROR in velocity observed in the DPD group was the result of excess velocity rather than bradykinesia, manifested as isolated deviations from the target trace in the DPD group that were coherent in time with increased ERROR in velocity. In conclusion, evidence presented in the present study shows that the LID was not the primary cause of the ERROR seen in the DPD group. Accordingly, we propose that the increased ERROR seen in the DPD group resulted from a mechanism distinct from the one generating LID.

Neurophysiologic intervention in deep brain stimulation treatment for movement disorders: a practical framework

Clinical neurophysiology has always played an important interventional role throughout the perioperative stages in functional neurosurgery. On the one hand, some neurophysiologic procedures have become an integrated part of neurosurgery. On the other hand, in deep brain stimulation, although the surgical electrode implantation is an essential step, the therapeutic effects are actually produced by electrically modulating the physiologic activity of the brain. We review the topic of neurophysiologic intervention in the deep brain stimulation for movement disorders by presenting the evidence derived from our own experiences based on an integrated group located at two hospitals in London and Oxford, UK, and mainly covering tremor caused by multiple sclerosis, Parkinson's disease and dystonia.

Quantifying drug-induced dyskinesias in the arms using digitised spiral-drawing tasks

In this study, we quantify the severity of drug-induced dyskinesias in the arms of Parkinson's disease (PD) patients using digitised spiral-drawing tasks. Two spiral drawings, namely a circular and a square spiral, are designed to, respectively, represent the continuous and discrete arm motions, and the size of the spiral is decided so that both the distal and proximal arm joints are involved. Fifteen PD patients, average disease duration 14.4+/-7.4 years, were assessed 30 min after a levodopa challenge whilst performing circular and square spiral-drawing tasks. The velocity of drawing movements was computed and the amplitude of the involuntary dyskinetic movements was measured as the standard deviation of the drawing velocity (SD-DV). The mean amplitude of dyskinetic movements was compared between arms and tasks and was correlated with clinical measures including the Bain dyskinesia scale and the total unified Parkinson's disease rating scale (UPDRS) score. The results showed that there was no statistically significant difference in the amplitude of dyskinesias either between the arms or between the continuous (circular) and discrete (square) spiral drawings in this group of PD patients, but interestingly the interaction between arm and drawing pattern was significant. Significant correlations were found between the magnitude of dyskinesia measured from the spiral-drawing tasks and both the 'on' or 'off' UPDRS and also the Bain dyskinesia scale. We conclude that the drawing tasks may be used to provide an objective method of quantifying the severity of drug-induced dyskinesias in the arm in PD patients.