Predictors of future falls in Parkinson disease

Background: Falls are a major health and injury problem for people with Parkinson disease (PD). Despite the severe consequences of falls, a major unresolved issue is the identification of factors that predict the risk of falls in individual patients with PD. The primary aim of this study was to prospectively determine an optimal combination of functional and disease-specific tests to predict falls in individuals with PD.

Methods: A total of 101 people with early-stage PD undertook a battery of neurologic and functional tests in their optimally medicated state. The tests included Tinetti, Berg, Timed Up and Go, Functional Reach, and the Physiological Profile Assessment of Falls Risk; the latter assessment includes physiologic tests of visual function, proprioception, strength, cutaneous sensitivity, reaction time, and postural sway. Falls were recorded prospectively over 6 months.

Results: Forty-eight percent of participants reported a fall and 24% more than 1 fall. In the multivariate model, a combination of the Unified Parkinson's Disease Rating Scale (UPDRS) total score, total freezing of gait score, occurrence of symptomatic postural orthostasis, Tinetti total score, and extent of postural sway in the anterior-posterior direction produced the best sensitivity (78%) and specificity (84%) for predicting falls. From the UPDRS items, only the rapid alternating task category was an independent predictor of falls. Reduced peripheral sensation and knee extension strength in fallers contributed to increased postural instability.

Conclusions: Falls are a significant problem in optimally medicated early-stage PD. A combination of both disease-specific and balance- and mobility-related measures can accurately predict falls in individuals with PD.

Motor learning processes in a movement-scaling task in olivopontocerebellar atrophy and Parkinson's disease

Nine Parkinson's disease (PD), seven olivopontocerebellar atrophy (OPCA) patients and two age-matched control groups learned a linear arm movement-scaling task over 2 days, requiring movements proportional in length to visually presented target-bars. Scaling was acquired through knowledge of results (KR concerning the direction and magnitude of errors) following every second acquisition trial. Initial acquisition of both groups was significantly worse than their respective controls (poorer movement scaling), but rapidly improved to nearly identical levels. Retention for the PD group's movement scaling was as good as controls initially, but markedly poorer after 24 h. The OPCA group did not show this deficit. Both patient groups extrapolated accurately to longer, previously unpracticed target distances (no KR provided), suggesting an unimpaired capacity to generate and use an internal representation of the movement scaling. They also rapidly learned a new scaling relationship when the gain was changed. Overall, the learning of this movement-scaling task was not adversely affected in OPCA, and the impairment was restricted primarily to longer-term retention in PD. The study suggests that: (1) the ability to acquire movement scaling in a task that requires conscious use of error feedback and no new coordination may depend little on the cerebellum, and (2) the basal ganglia may participate in longer-term storage of scaling information.

Peripheral constraint versus on-line programming in rapid aimed sequential movements

The purpose of this investigation was to examine how the programming and control of a rapid aiming sequence shifts with increased complexity. One objective was to determine if a preprogramming/peripheral constraint explanation is adequate to characterize control of an increasingly complex rapid aiming sequence, and if not, at what point on-line programming better accounts for the data. A second objective was to examine when on-line programming occurs. Three experiments were conducted in which complexity was manipulated by increasing the number of targets from 1 to 11. Initiation- and execution-timing patterns, probe reaction time (RT), and movement kinematics were measured. Results supported the peripheral constraint/pre-programming explanation for sequences up to 7 targets if they were executed in a blocked fashion. For sequences executed in a random fashion (one length followed by a different length), preprogramming did not increase with complexity, and on-line programming occurred without time cost. Across all sequences there was evidence that the later targets created a peripheral constraint on movements to previous targets. We suggest that programming is influenced by two factors: the overall spatial trajectory, which is consistent with Sidaway's subtended angle (SA) hypothesis (1991), and average velocity, with the latter established based on the number of targets in the sequence. As the number of targets increases, average velocity decreases, which controls variability of error in the extent of each movement segment. Overall the data support a continuous model of processing, one in which programming and execution co-occur, and can do so without time cost.

Proprioception and stimulus-response compatibility

Sixteen subjects pressed a left or right key in response to lateralized visual stimuli, in uncrossed (left index finger on left key, right finger on right key) and crossed conditions (left finger on right key and vice versa), with varying finger separations. Visual, tactile, or "efference copy" cues about relative finger positions were unavailable. Subjects had to press the key on the same side as (compatible group) or opposite side to the stimulus (incompatible group). Separate proprioceptive judgements of the relative finger positions were obtained. Findings of an overall reaction time (RT) advantage for compatible instructions and for uncrossed hands were replicated. With decreasing finger separation the RT advantage for compatible instructions decreased, and the probability of responding with either hand increased. The compatibility effect disappeared completely at the 6-cm crossed position, not at the position that was hardest to judge proprioceptively. This suggests that two forms of neural activation are summed: automatic activation of the anatomically same-side limb, and an integrated, rule-based activation. The results further demonstrate that independent proprioceptive cues from each limb, unassociated with skin contact between the limbs, can mediate the determination of relative position for response selection in stimulus-response compatibility tasks.

Directional stimulus-response compatibility: a test of three alternative principles

The basis of directional stimulus-response compatibility was studied using a task in which 128 participants moved a cursor into targets with a joystick, resembling the operation of certain industrial and construction equipment. Compatible and incompatible versions of three alternative compatibility principles were compared in all combinations. Visual Field (VF) compatibility was present if cursor and controlling limb movement were in the same direction in the visual field, Control Display (CD) compatibility meant that the control motion was in the same direction as, and parallel to, cursor motion, and Muscle Synergy (MS) compatibility was defined as use of the muscle synergy normally associated with the required direction as seen in the visual field. VF-compatible conditions had significantly shorter reaction, movement and homing times, and fewer reversal errors, for males and females, in two testing sites. These advantages were maintained over practice. VF compatibility was confirmed as a robust spatial compatibility principle that is affected by neither the orientation of the operator's limb or head nor the muscle synergy used in executing the task. It offers not only more rapid performance, but also a markedly reduced rate of potentially dangerous directional errors. The relationship between this finding and theoretical aspects of stimulus-response compatibility is discussed.

Distribution of programming in a rapid aimed sequential movement

Studies indicate that rapid sequential movements are preprogrammed and that preprogramming increases with complexity, but more complex sequences that require on-line programming have been seldom been studied. The purpose of this investigation was to determine whether on-line programming occurs in a 7-target sequence in which there is a unique target constraint and if so, to determine how different task constraints affect the distribution of additional programming. Subjects contacted seven targets with a hand-held stylus as quickly as possible while maintaining a 90% hit rate. Initiation-band execution-timing patterns and movement kinematics were measured to determine when the additional programming took place. Results indicated that additional programming occurred before initiation and during movement to the first target when the constraint required more spatial accuracy (small target). A different type of unique target (a triple hit of one target) caused the additional programming to occur on-line one or two segments before its execution. Different positions of the unique target also affected timing patterns. Results were discussed in terms of: (1) capacity of processing; (2) control of movement variance; and (3) mean velocity as a programmed parameter in sequential aiming movements.

An ultrasonic time-of-flight system for hand movement measurement

We have designed and built an ultrasonic time-of-flight system to measure the three-dimensional coordinates of up to three moving emitters. These emitters are fixed on the hand and arm of a human subject or on a hand-held stylus, to provide information concerning motor control. Three stationary receivers are suspended above the experimental space and provide three diagonal distances which are converted to x, y and z coordinates. The sampling rate for one emitter is 200-400 Hz, depending on the nature of the experiment. Multiple emitters are time-multiplexed. The piezoelectric resonator emitter is pulsed with 200 V for 12 microseconds of each cycle and rings at 40 kHz with a Q factor of four. The piezoelectric resonator receiver drives circuitry with a gain of 500 and a bandwidth of 60 kHz. The system provided highly linear results with a repeatability of +/- 1.64 mm and a resolution of 0.7 mm.

Variability Effects on the Internal Structure of Rapid Aiming Movements

Two experiments are reported in which the effects of different levels of spatial variability of the initial phase of aiming movements were explored. It was found that longer, faster, and more spatially variable initial sub movements were associated with an almost proportional increase in the distance between the average location at which the first submovement ended and the target. The first experiment involved a multisegmental arm motion that required a direction reversal, in which spatial variability could be estimated in all three dimensions. The second was a unidirectional, one-degree-of-freedom wrist supination task. The variability-amplitude relationship for the initial submovement was present in both. It is argued that the variability, or unpredictability, of the initial submovement is a determinant of its average amplitude, such that initial submovements approach the target as closely as is permitted by the level of variability. Such a mechanism allows task constraints such as accuracy requirements and allowable error rates to be met most efficiently, in a manner similar to the recently described optimization of submovement durations. If this mechanism is a general, ubiquitous phenomenon in rapid aiming, certain features of its internal kinematic structure are predictable. A set of five such predictions is outlined.

Practice effects on the preprogramming of discrete movements in Parkinson's disease

The effects of practice on the simple and choice reaction times (RTs) of Parkinson's disease (PD) and control subjects in a discrete aiming task were analysed. For controls, practice led to a selective decrease in choice RTs, as has been reported previously. An opposite effect was seen in the PD group, with little change in choice RTs and substantial reduction in simple RTs. The results suggest that PD subjects can use advance information to initiate discrete movements more rapidly, but that this ability to "preprogramme" movements requires practice. Reconciliation of these results with studies reporting an inability to preprogramme in PD are made in a discussion of task characteristics which may allow or preclude preprogramming.

Force production characteristics in Parkinson's disease

This experiment examined the preparation and the production of isometric force in Parkinson's disease (PD). PD patients, elderly, and young subjects generated force levels that were a percentage of their maximum (15, 30, 45, and 60%). Subjects were cued on the upcoming target force level and they were asked to produce the required response as fast as possible. PD patients showed a similar progression of force variability and dispersion of peak forces to that of control subjects, implying they have an accurate "internal model" of the required forces. Force production impairments were seen, however, at the within-trial level. PD patients had more irregular force-time curves that were characterized by changes in the rate of force production. The results suggest a more "noisy" output from the motor system and an inability to produce smooth forces. PD patients were also substantially slower in initiating a force production and the delay was localized in the pre-motor reaction time.

Preparatory processes in a case of hemi-parkinsonism

Reaction times and movement times were recorded in a subject with parkinsonian symptoms confined largely to the left side of the body. Advance information concerning the movement was varied, being with complete, partial or no preparation. The results suggest that processing of preparation for the movement is not qualitatively different for the more affected side, but is substantially slowed.

The control of bimanual aiming movements in Parkinson's disease

The control of unimanual and bimanual aiming movements by Parkinson's disease and control subjects was examined. Despite greater bimanual movement initiation asynchrony and overall bradykinesia, the Parkinson's disease subjects were affected by the experimental manipulations in the same way as controls. Symmetrical and, more especially, asymmetrical bimanual movements required more preparation time and were executed more slowly by both groups than were unimanual movements. Both groups also showed temporal linkage of movements to targets of different extents--movements which have different movement times when performed unimanually, as well as of the faster and slower limbs. A majority in both groups over-compensated for asynchrony in bimanual movement initiation by modulation of movement times, but there was no group difference in this tendency. The results are discussed in terms of underlying motor control processes and with regard to previous evidence for impaired control of simultaneous movements in Parkinson's disease.

The preparation and production of isometric force in Parkinson's disease

Subjects with Parkinson's disease (PD) and age-matched controls performed an isometric force production task, aiming at different target force levels without concurrent force feedback. Overall, PD subjects were as accurate as controls in attaining the target force levels, but executed the task differently. They had longer times to peak force and contraction durations, larger impulses and lower rates of force development, and force-time profiles with many more irregularities. They also initiated lower force contractions with longer latencies, unlike controls. The data suggest that PD subjects are deficient in the regulation of force and time parameters, rather than simply in force production. The ability to produce peak forces accurately limits the generality of previous assertions that PD subjects are heavily dependent on concurrent visual feedback.

The programming and execution of movement sequences in Parkinson's disease

Parkinsonian and neurologically normal subjects performed a finger-tapping task in which different sequence lengths had to be executed as rapidly as possible. For each response sequence, reaction time (RT), inter-tap-intervals (ITIs) and error patterns were recorded. It was found that the RT-sequence length relationship as well as the group ITI data were different for the two groups, indicative of impaired programming in the Parkinsonian subjects. This conclusion was supported by a relative dissociation of the first and subsequent taps and by a pattern of progressively increasing errors with longer tap sequences in the Parkinsonians.

Limb segment inclination sense in proprioception

Two experiments were performed to determine if proprioceptive signals are perceived more readily in terms of limb segment inclinations to the vertical than as joint angles. Subjects attempted to match arm positions with the upper arms supported at different inclinations. Constant error data showed that, when instructed to match forearm inclinations to the vertical, subjects were very accurate. When required to match elbow joint angles, however, errors were strongly biased in the direction of matching forearm inclinations. The results support a view of proprioception as a system in which afferent signals related to the gravitational torques acting at joints lead to the perception of limb orientation rather than joint angles. Such a system would allow more efficient determination of the relationship of limb segments to external objects than would one based purely on joint angles.

Movement preparation in Parkinson's disease. The use of advance information

The effects of advance information on movement planning in parkinsonism were assessed by means of movement precuing. Using this technique, the response latencies of identical sets of movements were compared across conditions in which the degree and type of advance movement information were manipulated. Specifically, prior information concerning three movement dimensions (the direction and extent of forthcoming movements, as well as the limb to be used) was or was not provided. Eight patients with Parkinson's disease and 8 neurologically normal age-matched controls served as subjects. The experiment showed that the elevated reaction times of the Parkinsonian subjects are not primarily caused by delays in response selection. Estimates of specification times for each of the three dimensions showed only a modest slowing in parkinsonians. The specification of those movement dimensions unknown before the response signal appears to occur serially, and can occur in a variable order as in normals. Since parkinsonians can initiate movements with shorter latencies when partial or complete information is available, albeit more slowly than normals, we conclude that response selection and specification processes preceding rapid discrete movements are relatively unaffected by the disease. The overall slowness in movement initiation in parkinsonians as compared with normals may in part be caused by excessive delays in motor time and, in general, to those 'input' and/or 'output' processes which are unaffected by advance information.

The contribution of gravitational torques to limb position sense

An experiment is reported which examined whether gravitational torque acting about a joint is used by the CNS in elbow joint angle matching. Subjects were required to match the joint angles of their two limbs while the external torques acting about each elbow were systematically varied. It was found that when the matching limb was differentially loaded, the error in the produced reference angle corresponded to the directional prediction of a proposed gravitational torque hypothesis. The data suggest that torque sensation is an accessory source of information in limb positioning.

Sensorimotor deficits related to postural stability. Implications for falling in the elderly

The effects of age-related sensorimotor and central processing deficits on postural control are reviewed, and the paucity of knowledge about proprioceptive changes with age is noted. A model of processing stages in the production of responses to postural instability is outlined. Even slight response slowing produces disproportionate increases in clinically slow responses. Many aspects of postural responses are "cognitively penetrable". Research on falls should examine learned as well as automated behaviors.