Suppression of enhanced physiological tremor via stochastic noise: initial observations

Application of vibration to the soles reduces minimum toe clearance variability during walking

Minimum toe clearance (MTC) is an important indicator of the risk of tripping. Aging and neuromuscular diseases often decrease MTC height and increase its variability, leading to a higher risk of tripping. Previous studies have developed visual feedback-based gait training systems to modify MTC. However, these systems are bulky and expensive, and the effects of the training continue only for a short time. We paid attention to the efficacy of vibration in decreasing the variability of gait parameters, and hypothesized that proper vibration applied to soles can reduce the MTC variability. Using shoes embedded with active vibrating insoles, we assessed the efficacy of both sub- and supra-threshold vibration in affecting MTC distribution. Experiment results with 17 young and healthy adults showed that vibration applied throughout the walking task with constant intensity of 130% of sensory threshold significantly decreased MTC variability, whereas sub-threshold vibration yielded no significant effect. These results demonstrate that a properly designed tactile sensory input which is controlled and delivered by a simple wearable device, the active insole, can reduce the MTC variability during walking.

Local Vibrational Therapy for Essential Tremor Reduction: A Clinical Study

Background and objectives: tremor is an unintentional and rhythmic movement of any part of the body that is a typical symptom of Essential Tremor (ET). ET impairs the quality of life of patients and is treated with pharmacotherapy. We investigated the tremor reduction efficacy of an innovative vibrational medical device (IMD) in ET patients. Materials and Methods: we conducted a prospective, single-center, single-arm, pragmatic study in ET patients with an extended safety study to evaluate the efficacy and safety of the Vilim Ball-a local hand-arm vibration device that produces vibrations in the frequency range of 8-18 Hz and amplitude from 0 to 2 mm. The primary endpoint was the decrease in the power spectrum after device use. The secondary endpoints were safety outcomes. Results: In total, 17 patients with ET were included in the main study, and no patients withdrew from the main study. The tremor power spectrum (m²/s³ Hz) was lower after the device use, represented as the mean (standard deviation): 0.106 (0.221); median (Md) 0.009 with the interquartile range; IQR, 0.087 vs. 0.042 (0.078); Md = 0.009 with the IQR 0.012; Wilcoxon signed-rank test V = 123; and p = 0.027. Seven patients reported that vibrational therapy was not effective. Two patients reported an increase in tremor after using the device. In the extended safety study, we included 51 patients: 31 patients with ET and 20 with Parkinsonian tremor, where 48 patients reported an improvement in tremor symptoms and 49 in function. No serious adverse events were reported, while two patients in the Parkinsonian tremor group reported a lack of efficacy of the proposed medical device. Conclusions: the device reduces essential tremor in some patients and is safe to use in ET.

Neurophysiological correlates of force control improvement induced by sinusoidal vibrotactile stimulation

OBJECTIVE

An optimal level of vibrotactile stimulation has been shown to improve sensorimotor control in healthy and diseased individuals. However, the underlying neurophysiological mechanisms behind the enhanced motor performance caused by vibrotactile stimulation are yet to be fully understood. Therefore, here we aim to evaluate the effect of a cutaneous vibration on the firing behavior of motor units in a condition of improved force steadiness.

APPROACH

Participants performed a visuomotor task, which consisted of low-intensity isometric contractions of the first dorsal interosseous (FDI) muscle, while sinusoidal (175 Hz) vibrotactile stimuli with different intensities were applied to the index finger. High-density surface electromyogram was recorded from the FDI muscle, and a decomposition algorithm was used to extract the motor unit spike trains. Additionally, computer simulations were performed using a multiscale neuromuscular model to provide a potential explanation for the experimental findings.

MAIN RESULTS

Experimental outcomes showed that an optimal level of vibration significantly improved force steadiness (estimated as the coefficient of variation of force). The decreased force variability was accompanied by a reduction in the variability of the smoothed cumulative spike train (as an estimation of the neural drive to the muscle), and the proportion of common inputs to the FDI motor nucleus. However, the interspike interval variability did not change significantly with the vibration. A mathematical approach, together with computer simulation results suggested that vibrotactile stimulation would reduce the variance of the common synaptic input to the motor neuron pool, thereby decreasing the low frequency fluctuations of the neural drive to the muscle and force steadiness.

SIGNIFICANCE

Our results demonstrate that the decreased variability in common input accounts for the enhancement in force control induced by vibrotactile stimulation.

The effect of imperceptible Gaussian tendon vibration on the Hoffmann reflex

Imperceptible vibratory Gaussian noise stimulation to the periphery is frequently being applied to humans to enhance motor performance. It is commonly theorized that this stimulation creates a Stochastic Resonance-like effect across both sensory and motor systems, but this idea has no empirical support. In contrast, there is substantial work showing that tendon vibration can be both excitatory and inhibitory on the lower motor neuron output. In this work, we demonstrate that delivery of imperceptible vibratory Gaussian noise stimulation to the wrist flexor tendons results in a 27% increase in excitability of the lower motor neuron pool in the median nerve, as evidenced by changes in the Hoffmann reflex. We argue that the well-documented tonic vibration reflex is a sufficient mechanistic explanation for the behavioral changes observed during the introduction of vibratory noise stimulation.

The Promise of Stochastic Resonance in Falls Prevention

Multisensory integration is essential for maintenance of motor and cognitive abilities, thereby ensuring normal function and personal autonomy. Balance control is challenged during senescence or in motor disorders, leading to potential falls. Increased uncertainty in sensory signals is caused by a number of factors including noise, defined as a random and persistent disturbance that reduces the clarity of information. Counter-intuitively, noise can be beneficial in some conditions. Stochastic resonance is a mechanism whereby a particular level of noise actually enhances the response of non-linear systems to weak sensory signals. Here we review the effects of stochastic resonance on sensory modalities and systems directly involved in balance control. We highlight its potential for improving sensorimotor performance as well as cognitive and autonomic functions. These promising results demonstrate that stochastic resonance represents a flexible and non-invasive technique that can be applied to different modalities simultaneously. Finally we point out its benefits for a variety of scenarios including in ambulant elderly, skilled movements, sports and to patients with sensorimotor or autonomic dysfunctions.

Differential diagnosis between Parkinson's disease and essential tremor using the smartphone's accelerometer

Background

The differential diagnosis between patients with essential tremor (ET) and those with Parkinson’s disease (PD) whose main manifestation is tremor may be difficult unless using complex neuroimaging techniques such as ¹²³I-FP-CIT SPECT. We considered that using smartphone’s accelerometer to stablish a diagnostic test based on time-frequency differences between PD an ET could support the clinical diagnosis.

Methods

The study was carried out in 17 patients with PD, 16 patients with ET, 12 healthy volunteers and 7 patients with tremor of undecided diagnosis (TUD), who were re-evaluated one year after the first visit to reach the definite diagnosis. The smartphone was placed over the hand dorsum to record epochs of 30 s at rest and 30 s during arm stretching. We generated frequency power spectra and calculated receiver operating characteristics curves (ROC) curves of total spectral power, to establish a threshold to separate subjects with and without tremor. In patients with PD and ET, we found that the ROC curve of relative energy was the feature discriminating better between the two groups. This threshold was then used to classify the TUD patients.

Results

We could correctly classify 49 out of 52 subjects in the category with/without tremor (97.96% sensitivity and 83.3% specificity) and 27 out of 32 patients in the category PD/ET (84.38% discrimination accuracy). Among TUD patients, 2 of 2 PD and 2 of 4 ET were correctly classified, and one patient having PD plus ET was classified as PD.

Conclusions

Based on the analysis of smartphone accelerometer recordings, we found several kinematic features in the analysis of tremor that distinguished first between healthy subjects and patients and, ultimately, between PD and ET patients. The proposed method can give immediate results for the clinician to gain valuable information for the diagnosis of tremor. This can be useful in environments where more sophisticated diagnostic techniques are unavailable.

Emotions alter muscle proprioceptive coding of movements in humans

Emotions can evoke strong reactions that have profound influences, from gross changes in our internal environment to small fluctuations in facial muscles, and reveal our feelings overtly. Muscles contain proprioceptive afferents, informing us about our movements and regulating motor activities. Their firing reflects changes in muscle length, yet their sensitivity can be modified by the fusimotor system, as found in animals. In humans, the sensitivity of muscle afferents is modulated by cognitive processes, such as attention; however, it is unknown if emotional processes can modulate muscle feedback. Presently, we explored whether muscle afferent sensitivity adapts to the emotional situation. We recorded from single muscle afferents in the leg, using microneurography, and moved the ankle joint of participants, while they listened to evocative classical music to induce sad, neutral, or happy emotions, or sat passively (no music). We further monitored their physiological responses using skin conductance, heart rate, and electromyography measures. We found that muscle afferent firing was modified by the emotional context, especially for sad emotions, where the muscle spindle dynamic response increased. We suggest that this allows us to prime movements, where the emotional state prepares the body for consequent behaviour-appropriate reactions.

Plastic Changes in Human Motor Cortical Output Induced by Random but not Closed-Loop Peripheral Stimulation: the Curse of Causality

Previous work showed that repetitive peripheral nerve stimulation can induce plastic changes in motor cortical output. Triggering electrical stimulation of central structures from natural activity can also generate plasticity. In this study, we tested whether triggering peripheral nerve stimulation from muscle activity would likewise induce changes in motor output. We developed a wearable electronic device capable of recording electromyogram (EMG) and delivering electrical stimulation under closed-loop control. This allowed paired stimuli to be delivered over longer periods than standard laboratory-based protocols. We tested this device in healthy human volunteers. Motor cortical output in relaxed thenar muscles was first assessed via the recruitment curve of responses to contralateral transcranial magnetic stimulation. The wearable device was then configured to record thenar EMG and stimulate the median nerve at the wrist (intensity around motor threshold, rate ~0.66 Hz). Subjects carried out normal daily activities for 4-7 h, before returning to the laboratory for repeated recruitment curve assessment. Four stimulation protocols were tested (9-14 subjects each): No Stim, no stimuli delivered; Activity, stimuli triggered by EMG activity above threshold; Saved, stimuli timed according to a previous Activity session in the same subject; Rest, stimuli given when EMG was silent. As expected, No Stim did not modify the recruitment curve. Activity and Rest conditions produced no significant effects across subjects, although there were changes in some individuals. Saved produced a significant and substantial increase, with average responses 2.14 times larger at 30% stimulator intensity above threshold. We argue that unavoidable delays in the closed loop feedback, due mainly to central and peripheral conduction times, mean that stimuli in the Activity paradigm arrived too late after cortical activation to generate consistent plastic changes. By contrast, stimuli delivered essentially at random during the Saved paradigm may have caused a generalized increase in cortical excitability akin to stochastic resonance, leading to plastic changes in corticospinal output. Our study demonstrates that non-invasive closed loop stimulation may be critically limited by conduction delays and the unavoidable constraint of causality.

Exploring the effect of electrical muscle stimulation as a novel treatment of intractable tremor in Parkinson's disease

BACKGROUND

As the pathophysiology of tremor in Parkinson disease (PD) involves a complex interaction between central and peripheral mechanisms, we propose that modulation of peripheral reflex mechanism by electrical muscle stimulation (EMS) may improve tremor temporarily.

OBJECTIVES

To determine the efficacy of EMS as a treatment for drug resistant tremor in PD patients.

METHODS

This study was a single-blinded, quasi-experimental study involving 34 PD patients with classic resting tremor as confirmed by tremor analysis. The EMS was given at 50Hz over the abductor pollicis brevis and interrosseus muscles for 10s with identified tremor parameters before and during stimulation as primary outcomes.

RESULTS

Compared to before stimulation, we observed a significant reduction in the root mean square (RMS) of the angular velocity (p<0.001) and peak magnitude (p<0.001) of resting tremor while tremor frequency (p=0.126) and dispersion (p=0.284) remained unchanged during stimulation. The UPDRS tremor score decreased from 10.59 (SD=1.74) before stimulation to 8.85 (SD=2.19) during stimulation (p<0.001). The average percentage of improvement of the peak magnitude and RMS angular velocity was 49.57% (SD=38.89) and 43.81% (SD=33.15) respectively. 70.6% and 61.8% of patients experienced at least 30% tremor attenuation as calculated from the peak magnitude and RMS angular velocity respectively.

CONCLUSIONS

Our study demonstrated the efficacy of EMS in temporarily improving resting tremor in medically intractable PD patients. Although tremor severity decreased, they were not completely eliminated and continued with a similar frequency, thus demonstrating the role of peripheral reflex mechanism in the modulation of tremor, but not as a generator. EMS should be further explored as a possible therapeutic intervention for tremor in PD.

Effect of mechanical tactile noise on amplitude of visual evoked potentials: multisensory stochastic resonance

The present investigation documents the electrophysiological occurrence of multisensory stochastic resonance in the human visual pathway elicited by tactile noise. We define multisensory stochastic resonance of brain evoked potentials as the phenomenon in which an intermediate level of input noise of one sensory modality enhances the brain evoked response of another sensory modality. Here we examined this phenomenon in visual evoked potentials (VEPs) modulated by the addition of tactile noise. Specifically, we examined whether a particular level of mechanical Gaussian noise applied to the index finger can improve the amplitude of the VEP. We compared the amplitude of the positive P100 VEP component between zero noise (ZN), optimal noise (ON), and high mechanical noise (HN). The data disclosed an inverted U-like graph for all the subjects, thus demonstrating the occurrence of a multisensory stochastic resonance in the P100 VEP.