Motor Output Variability in Movement Disorders: Insights From Essential Tremor.

Findings on individuals with essential tremor suggest that tremor (within-trial movement unsteadiness) and inconsistency (trial-to-trial movement variance) stem from distinct pathologies and affect function uniquely. Nonetheless, the intricacies of inconsistency in movement disorders remain largely unexplored, as exemplified in ataxia where inconsistency below healthy levels is associated with greater pathology. We advocate for clinical assessments that quantify both tremor and inconsistency.

Physical urticaria: Clinical features, pathogenesis, diagnostic work-up, and management.

Physical urticaria is a type of urticaria in which recurrent wheals and/or angioedema occur following exposure of the skin to a physical stimulus. It is classified according to its triggers, which may be mechanical (friction, pressure, and vibration), thermal (cold and heat), or solar electromagnetic radiation. Symptoms of different physical urticarias can develop following specific activities that expose patients to an eliciting stimulus and may be variably accompanied by mucosal involvement and systemic symptoms, including nausea, headache, or even anaphylaxis. Differentiation of physical urticaria from other chronic urticarias requires careful clinical assessment and confirmatory provocation testing, which in turn can inform appropriate management. This clinical review provides an evidence-based summary of the epidemiology, clinical features, pathogenesis, diagnostic work-up, and management of physical urticaria.

Adolescent boys who participate in sports exhibit similar ramp torque control with young men despite differences in strength and tendon characteristics.

PURPOSE: The goal of this paper was to determine if sports participation influences torque control differently for adolescent boys and young men during a slow ramp task. METHODS: Twenty-one adolescent boys (11 athletes) and 31 young men (16 athletes) performed a slow ramp increase in plantar flexion torque from 0 to maximum. We quantified torque control as the coefficient of variation (CV) of torque during the ramp and quantified the Achilles tendon mechanical properties using ultrasonography. RESULTS: Relative to adolescent boys, young men were taller, heavier, stronger, and had a longer and stiffer Achilles tendon. However, these characteristics were not different between athletes and non-athletes in adolescent boys. For the CV of torque, there was a significant interaction with sports participation, indicating that only adolescent boys who were non-athletes had greater variability than young men. The CV of torque of all participants was predicted from the maximum torque and torque oscillations from 1 to 2 Hz, whereas the CV of torque for adolescent boys was predicted only from torque oscillations from 1 to 2 Hz. CONCLUSION: These findings suggested that adolescent boys who participate in sports exhibited lower torque variability during a slow ramp task, which was not explained by differences in Achilles tendon properties or strength.

Sex differences in cognitive-motor components of braking in older adults.

Fast and accurate braking is essential for safe driving and relies on efficient cognitive and motor processes. Despite the known sex differences in overall driving behavior, it is unclear whether sex differences exist in the objective assessment of driving-related tasks in older adults. Furthermore, it is unknown whether cognitive-motor processes are differentially affected in men and women with advancing age. We aimed to determine sex differences in the cognitive-motor components of the braking performance in older adults. Fourteen men (63.06 ± 8.53 years) and 14 women (67.89 ± 11.81 years) performed a braking task in a simulated driving environment. Participants followed a lead car and applied a quick and controlled braking force in response to the rear lights of the lead car. We quantified braking accuracy and response time. Importantly, we also decomposed response time in its cognitive (pre-motor response time) and motor (motor response time) components. Lastly, we examined whether sex differences in the activation and coordination of the involved muscles could explain differences in performance. We found sex differences in the cognitive-motor components of braking performance with advancing age. Specifically, the cognitive processing speed is 27.41% slower in women, while the motor execution speed is 24.31% slower in men during the braking task. The opposite directions of impairment in the cognitive and motor speeds contributed to comparable overall braking speed across sexes. The sex differences in the activation of the involved muscles did not relate to response time differences between men and women. The exponential increase in the number of older drivers raises concerns about potential effects on traffic and driver safety. We demonstrate the presence of sex differences in the cognitive-motor components of braking performance with advancing age. Driving rehabilitation should consider differential strategies for ameliorating sex-specific deficits in cognitive and motor speeds to enhance braking performance in older adults.

Temporal Invariance in SCA6 Is Related to Smaller Cerebellar Lobule VI and Greater Disease Severity.

Regulating muscle force and timing are fundamental for accurate motor performance. In spinocerebellar ataxia type 6 (SCA6), there is evidence that individuals have greater force dysmetria but display better temporal accuracy during fast goal directed contractions. Here, we test whether greater temporal accuracy occurs in all individuals with SCA6, and can be explained by lesser temporal variability. Further we examine whether it is linked to disease severity and specific degenerative changes in the cerebellum. Nineteen human participants with SCA6 (13 woman) and 18 healthy controls performed fast goal-directed ankle dorsiflexion contractions aiming at a spatiotemporal target. We quantified the endpoint control of these contractions, gray matter (GM) integrity of the cerebellum, and disease severity using the International Cooperative Ataxia Rating Scale (ICARS). SCA6 individuals exhibited lower temporal endpoint error and variability than the healthy controls (p = 0.008). Statistically, SCA6 clustered into two distinct groups for temporal variability. A group with low temporal variability ranging from 10 to 19% (SCA6a) and a group with temporal variability similar to healthy controls (SCA6b; 19-40%).SCA6a exhibited greater disease severity than SCA6b, as assessed with ICARS (p < 0.001). Lower temporal variability, which was not associated with disease duration (R2 = 0.1, p > 0.2), did correlate with both greater ICARS (R2 = 0.3) and reduced GM volume in cerebellar lobule VI (R2 = 0.35). Other cerebellar lobules did not relate to temporal variability. We provide new evidence that a subset of SCA6 with greater loss of GM in cerebellum lobule VI exhibit temporal invariance and more severe ataxia than other SCA6 individuals.SIGNIFICANCE STATEMENT Variability is an inherent feature of voluntary movement, and traditionally more variability in the targeted output infers impaired performance. For example, cerebellar patients present exacerbated temporal variability during multijoint movements, which is thought to contribute to their motor deficits. In the current work, we show that in a subgroup of spinocerebellar ataxia type 6 individuals, temporal variability is lower than that of healthy controls when performing single-joint fast-goal directed movements. This invariance related to exacerbated atrophy of lobule VI of the cerebellum and exacerbated disease severity. The relation between invariance and disease severity suggests that pathological motor variability can manifest not only as an exacerbation but also as a reduction relative to healthy controls.

Quantitative Separation of Tremor and Ataxia in Essential Tremor.

OBJECTIVE: This study addresses an important problem in neurology, distinguishing tremor and ataxia using quantitative methods. Specifically, we aimed to quantitatively separate dysmetria, a cardinal sign of ataxia, from tremor in essential tremor (ET). METHODS: In Experiment 1, we compared 19 participants diagnosed with ET undergoing thalamic deep brain stimulation (DBS; ETDBS ) to 19 healthy controls (HC). We quantified tremor during postural tasks using accelerometry and dysmetria with fast, reverse-at-target goal-directed movements. To ensure that endpoint accuracy was unaffected by tremor, we quantified dysmetria in selected trials manifesting a smooth trajectory to the endpoint. Finally, we manipulated tremor amplitude by switching DBS ON and OFF to examine its effect on dysmetria. In Experiment 2, we compared 10 ET participants with 10 HC to determine whether we could identify and distinguish dysmetria from tremor in non-DBS ET. RESULTS: Three findings suggest that we can quantify dysmetria independently of tremor in ET. First, ETDBS and ET exhibited greater dysmetria than HC and dysmetria did not correlate with tremor (R2 < 0.01). Second, even for trials with tremor-free trajectories to the target, ET exhibited greater dysmetria than HC (p < 0.01). Third, activating DBS reduced tremor (p < 0.01) but had no effect on dysmetria (p > 0.2). INTERPRETATION: We demonstrate that dysmetria can be quantified independently of tremor using fast, reverse-at-target goal-directed movements. These results have important implications for the understanding of ET and other cerebellar and tremor disorders. Future research should examine the neurophysiological mechanisms underlying each symptom and characterize their independent contribution to disability. ANN NEUROL 2020;88:375-387.

Rehabilitation with accurate adaptability walking tasks or steady state walking: A randomized clinical trial in adults post-stroke.

OBJECTIVE: To assess changes in walking function and walking-related prefrontal cortical activity following two post-stroke rehabilitation interventions: an accurate adaptability (ACC) walking intervention and a steady state (SS) walking intervention. DESIGN: Randomized, single blind, parallel group clinical trial. SETTING: Hospital research setting. SUBJECTS: Adults with chronic post-stroke hemiparesis and walking deficits. INTERVENTIONS: ACC emphasized stepping accuracy and walking adaptability, while SS emphasized steady state, symmetrical stepping. Both included 36 sessions led by a licensed physical therapist. ACC walking tasks recruit cortical regions that increase corticospinal tract activation, while SS walking activates the corticospinal tract less intensely. MAIN MEASURES: The primary functional outcome measure was preferred steady state walking speed. Prefrontal brain activity during walking was measured with functional near infrared spectroscopy to assess executive control demands. Assessments were conducted at baseline, post-intervention (three months), and follow-up (six months). RESULTS: Thirty-eight participants were randomized to the study interventions (mean age 59.6 ± 9.1 years; mean months post-stroke 18.0 ± 10.5). Preferred walking speed increased from baseline to post-intervention by 0.13 ± 0.11 m/s in the ACC group and by 0.14 ± 0.13 m/s in the SS group. The Time × Group interaction was not statistically significant (P = 0.86). Prefrontal fNIRS during walking decreased from baseline to post-intervention, with a marginally larger effect in the ACC group (P = 0.05). CONCLUSIONS: The ACC and SS interventions produced similar changes in walking function. fNIRS suggested a potential benefit of ACC training for reducing demand on prefrontal (executive) resources during walking.

Cognitive and motor deficits contribute to longer braking time in stroke.

BACKGROUND: Braking is a critical determinant of safe driving that depends on the integrity of cognitive and motor processes. Following stroke, both cognitive and motor capabilities are impaired to varying degrees. The current study examines the combined impact of cognitive and motor impairments on braking time in chronic stroke. METHODS: Twenty stroke survivors and 20 aged-matched healthy controls performed cognitive, motor, and simulator driving assessments. Cognitive abilities were assessed with processing speed, divided attention, and selective attention. Motor abilities were assessed with maximum voluntary contraction (MVC) and motor accuracy of the paretic ankle. Driving performance was examined with the braking time in a driving simulator and self-reported driving behavior. RESULTS: Braking time was 16% longer in the stroke group compared with the control group. The self-reported driving behavior in stroke group was correlated with braking time (r = - 0.53, p = 0.02). The stroke group required significantly longer time for divided and selective attention tasks and showed significant decrease in motor accuracy. Together, selective attention time and motor accuracy contributed to braking time (R2 = 0.40, p = 0.01) in stroke survivors. CONCLUSIONS: This study provides novel evidence that decline in selective attention and motor accuracy together contribute to slowed braking in stroke survivors. Driving rehabilitation after stroke may benefit from the assessment and training of attentional and motor skills to improve braking during driving.

Temporal but not spatial dysmetria relates to disease severity in FA.

Friedreich's ataxia (FA) is an inherited disease that causes degeneration of the nervous system. Features of FA include proprioceptive and cerebellar deficits leading to impaired muscle coordination and, consequently, dysmetria in force and time of movement. The aim of this study is to characterize dysmetria and its association to disease severity. Also, we examine the neural mechanisms of dysmetria by quantifying the EMG burst area, duration, and time-to-peak of the agonist muscle. Twenty-seven individuals with FA and 13 healthy controls (HCs) performed the modified Functional Ataxia Rating Scale and goal-directed movements with the ankle. Dysmetria was quantified as position and time error during dorsiflexion. FA individuals exhibited greater time but not position error than HCs. Moreover, time error correlated with disease severity and was related to increased agonist EMG burst. Temporal dysmetria is associated to disease severity, likely due to altered activation of the agonist muscle.NEW & NOTEWORTHY For the first time, we quantified spatial and temporal dysmetria and its relation to disease severity in Friedreich's ataxia (FA). We found that FA individuals exhibit temporal but not spatial dysmetria relative to healthy controls. Temporal dysmetria correlated to disease severity in FA and was predicted from an altered activation of the agonist muscle. Therefore, these results provide novel evidence that FA exhibit temporal but not spatial dysmetria, which is different from previous findings on SCA6.

High Tolerability of Pitavastatin Therapy: A Case Report of Comparison with other Statins.

INTRODUCTION: Myopathy is possibly the most clinically relevant statin-induced side effect. CASE PRESENTATION: We report a case of a 63-year-old healthy male with mixed dyslipidemia. He developed bilateral myalgia of the forearms with fluvastatin 40 mg/day, pravastatin 20 mg/day, and combination of atorvastatin 10 mg and ezetimibe 10 mg/day. The only hypolipidemic treatment that was tolerable was the combination of pitavastatin 1 mg and ezetimibe 10 mg/day. DISCUSSION: Pitavastatin demonstrated less potential for the development of myalgia compared to the so far considered most tolerable statins (i.e., fluvastatin and pravastatin). All the tested statins were used at the lowest approved dose for clinical use. CONCLUSION: The combination of pitavastatin 1 mg and ezetimibe appears to be a promising treatment choice for individuals who are intolerant to statin therapy due to muscle complaints.

Functional motor control deficits in older FMR1 premutation carriers.

Individuals with fragile X mental retardation 1 (FMR1) gene premutations are at increased risk for fragile X-associated tremor/ataxia syndrome (FXTAS) during aging. However, it is unknown whether older FMR1 premutation carriers, with or without FXTAS, exhibit functional motor control deficits compared with healthy individuals. The purpose of this study, therefore, was to determine whether older FMR1 premutation carriers exhibit impaired ability to perform functional motor tasks. Eight FMR1 premutation carriers (age: 58.88 ± 8.36 years) and eight age- and sex-matched healthy individuals (60.13 ± 9.25 years) performed (1) a steady isometric force control task with the index finger at 20% of their maximum voluntary contraction (MVC) and; (2) a single-step task. During the finger abduction task, firing rate of multiple motor units of the first dorsal interosseous (FDI) muscle was recorded. Compared with healthy controls, FMR1 premutation carriers exhibited (1) greater force variability (coefficient of variation of force) during isometric force (1.48 ± 1.02 vs. 0.63 ± 0.37%; P = 0.04); (2) reduced firing rate of multiple motor units during steady force, and; (3) reduced velocity of their weight transfer during stepping (156.62 ± 26.24 vs. 191.86 ± 18.83 cm/s; P = 0.01). These findings suggest that older FMR1 premutation carriers exhibit functional motor control deficits that reflect either subclinical issues associated with premutations independent of FXTAS, or prodromal markers of the development of FXTAS.

Lower Extremity Muscle Strength and Force Variability in Persons With Parkinson Disease.

BACKGROUND AND PURPOSE: Adequate lower limb strength and motor control are essential for mobility and quality of life. People with Parkinson disease (PD) experience a significant and progressive decline in motor capabilities as part of this neurodegenerative disease. The primary objective of this study was to examine the effect of PD on (1) muscular strength and (2) force steadiness in muscles that are primarily responsible for locomotion and stability. METHODS: Thirteen persons with PD and 13 healthy age-matched controls participated. Participants performed maximal and submaximal (5%, 10%, and 20% maximum voluntary contractions) isometric force tasks with the limb stabilized in a customized device. Strength of the hip extensors and flexors, hip abductors and adductors, and ankle plantar flexors and dorsiflexors was quantified based on data obtained from force transducers, with the relevant joint stabilized in standardized positions. RESULTS: Individuals with PD were weaker and exhibited higher amounts of force variability than controls across the lower extremity. Reduced strength was greatest in the hip flexors (2.0 N/kg vs 2.6 N/kg) and ankle plantar flexors (1.74 N/kg vs 2.64 N/kg) and dorsiflexors (1.9 N/kg vs 2.3 N/kg). Force steadiness was impaired in the hip flexors, ankle plantar flexors, and dorsiflexors. DISCUSSION AND CONCLUSIONS: Reduced maximal force production was concomitant with impaired force control within the muscles that are critical for effective ambulation (hip flexion, ankle dorsiflexion, and ankle plantar flexion). These features should be evaluated when considering contributors to reduced mobility and quality of life.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A241).

Visual information processing in older adults: reaction time and motor unit pool modulation.

Presently, there is no evidence that magnification of visual feedback has motor implications beyond impairments in force control during a visuomotor task. We hypothesized that magnification of visual feedback would increase visual information processing, alter the muscle activation, and exacerbate the response time in older adults. To test this hypothesis, we examined whether magnification of visual feedback during a reaction time task alters the premotor time and the motor unit pool activation of older adults. Participants responded as fast as possible to a visual stimulus while they maintained a steady ankle dorsiflexion force (15% maximum) either with low-gain or high-gain visual feedback of force. We quantified the following: 1) response time and its components (premotor and motor time), 2) force variability, and 3) motor unit pool activity of the tibialis anterior muscle. Older adults exhibited longer premotor time and greater force variability than young adults. Only in older adults, magnification of visual feedback lengthened the premotor time and exacerbated force variability. The slower premotor time in older adults with high-gain visual feedback was associated with increased force variability and an altered modulation of the motor unit pool. In conclusion, our findings provide novel evidence that magnification of visual feedback also exacerbates premotor time during a reaction time task in older adults, which is correlated with force variability and an altered modulation of motor unit pool. Thus these findings suggest that visual information processing deficiencies in older adults could result in force control and reaction time impairments. NEW & NOTEWORTHY It is unknown whether magnification of visual feedback has motor implications beyond impairments in force control for older adults. We examined whether it impairs reaction time and motor unit pool activation. The findings provide novel evidence that magnification of visual feedback exacerbates reaction time by lengthening premotor time, which implicates time for information processing in older adults, which is correlated with force variability and an altered modulation of motor unit pool.

Motor planning perturbation: muscle activation and reaction time.

Reaction time (RT) is the time interval between the appearance of a stimulus and initiation of a motor response. Within RT, two processes occur, selection of motor goals and motor planning. An unresolved question is whether perturbation to the motor planning component of RT slows the response and alters the voluntary activation of muscle. The purpose of this study was to determine how the modulation of muscle activity during an RT response changes with motor plan perturbation. Twenty-four young adults (20.5 ±1.1 yr, 13 women) performed 15 trials of an isometric RT task with ankle dorsiflexion using a sinusoidal anticipatory strategy (10-20% maximum voluntary contraction). We compared the processing part of the RT and modulation of muscle activity from 10 to 60 Hz of the tibialis anterior (primary agonist) when the stimulus appeared at the trough or at the peak of the sinusoidal task. We found that RT ( P = 0.003) was longer when the stimulus occurred at the peak compared with the trough. During the time of the reaction, the electromyography (EMG) power from 10 to 35 Hz was less at the peak than the trough ( P = 0.019), whereas the EMG power from 35 to 60 Hz was similar between the peak and trough ( P = 0.92). These results suggest that perturbation to motor planning lengthens the processing part of RT and alters the voluntary activation of the muscle by decreasing the relative amount of power from 10 to 35 Hz. NEW & NOTEWORTHY We aimed to determine whether perturbation to motor planning would alter the speed and muscle activity of the response. We compared trials when a stimulus appeared at the peak or trough of an oscillatory reaction time task. When the stimulus occurred at the trough, participants responded faster, with greater force, and less EMG power from 10-35 Hz. We provide evidence that motor planning perturbation slows the response and alters the voluntary activity of the muscle.

Speed but not amplitude of visual feedback exacerbates force variability in older adults.

Magnification of visual feedback (VF) impairs force control in older adults. In this study, we aimed to determine whether the age-associated increase in force variability with magnification of visual feedback is a consequence of increased amplitude or speed of visual feedback. Seventeen young and 18 older adults performed a constant isometric force task with the index finger at 5% of MVC. We manipulated the vertical (force gain) and horizontal (time gain) aspect of the visual feedback so participants performed the task with the following VF conditions: (1) high amplitude-fast speed; (2) low amplitude-slow speed; (3) high amplitude-slow speed. Changing the visual feedback from low amplitude-slow speed to high amplitude-fast speed increased force variability in older adults but decreased it in young adults (P < 0.01). Changing the visual feedback from low amplitude-slow speed to high amplitude-slow speed did not alter force variability in older adults (P > 0.2), but decreased it in young adults (P < 0.01). Changing the visual feedback from high amplitude-slow speed to high amplitude-fast speed increased force variability in older adults (P < 0.01) but did not alter force variability in young adults (P > 0.2). In summary, increased force variability in older adults with magnification of visual feedback was evident only when the speed of visual feedback increased. Thus, we conclude that in older adults deficits in the rate of processing visual information and not deficits in the processing of more visual information impair force control.

Motor plan differs for young and older adults during similar movements.

Older adults exhibit altered activation of the agonist and antagonist muscles during goal-directed movements compared with young adults. However, it remains unclear whether the differential activation of the antagonistic muscles in older adults results from an impaired motor plan or an altered ability of the muscle to contract. The purpose of this study, therefore, was to determine whether the motor plan differs for young and older adults. Ten young (26.1 ± 4.3 yr, 4 women) and 16 older adults (71.9 ± 6.9 yr, 9 women) participated in the study. Participants performed 100 trials of fast goal directed movements with ankle dorsiflexion while we recorded the electromyographic activity of the primary agonist (tibialis anterior; TA) and antagonist (soleus; SOL) muscles. From those 100 trials we selected 5 trials in each of 3 movement end-point categories (fast, accurate, and slow). We investigated age-associated differences in the motor plan by quantifying the individual activity and coordination of the agonist and antagonist muscles. During similar movement end points, older adults exhibited similar activation of the agonist (TA) and antagonist (SOL) muscles compared with young adults. In addition, the coordination of the agonist and antagonist muscles (TA and SOL) was different between the two age groups. Specifically, older adults exhibited lower TA-SOL overlap (F1,23 = 41.2, P < 0.001) and greater TA-SOL peak EMG delay (F1,25 = 35.5, P < 0.001). This finding suggests that although subjects in both age groups displayed similar movement end points, they exhibited a different motor plan, as demonstrated by altered coordination between the agonist and antagonist muscles.NEW & NOTEWORTHY We aimed to determine whether the altered activation of muscles in older adults compared with young adults during fast goal-directed movements is related to an altered motor plan. For matched movements, there were differences in the coordination of antagonistic muscles but no differences in the individual activation of muscles. We provide novel evidence that the differential activation of muscles in older adults is related to an altered motor plan.

Voluntary reduction of force variability via modulation of low-frequency oscillations.

Visual feedback can influence the force output by changing the power in frequencies below 1 Hz. However, it remains unknown whether visual guidance can help an individual reduce force variability voluntarily. The purpose of this study, therefore, was to determine whether an individual can voluntarily reduce force variability during constant contractions with visual guidance, and whether this reduction is associated with a decrease in the power of low-frequency oscillations (0-1 Hz) in force and muscle activity. Twenty young adults (27.6 ± 3.4 years) matched a force target of 15% MVC (maximal voluntary contraction) with ankle dorsiflexion. Participants performed six visually unrestricted contractions, from which we selected the trial with the least variability. Following, participants performed six visually guided contractions and were encouraged to reduce their force variability within two guidelines (±1 SD of the least variable unrestricted trial). Participants decreased the SD of force by 45% (P < 0.001) during the guided condition, without changing mean force (P > 0.2). The decrease in force variability was associated with decreased low-frequency oscillations (0-1 Hz) in force (R 2 = 0.59), which was associated with decreased low-frequency oscillations in EMG bursts (R 2 = 0.35). The reduction in low-frequency oscillations in EMG burst was positively associated with power in the interference EMG from 35 to 60 Hz (R 2 = 0.47). In conclusion, voluntary reduction of force variability is associated with decreased low-frequency oscillations in EMG bursts and consequently force output. We provide novel evidence that visual guidance allows healthy young adults to reduce force variability voluntarily likely by adjusting the low-frequency oscillations in the neural drive.

Sex differences in spatial accuracy relate to the neural activation of antagonistic muscles in young adults.

Sex is an important physiological variable of behavior, but its effect on motor control remains poorly understood. Some evidence suggests that women exhibit greater variability during constant contractions and poorer accuracy during goal-directed tasks. However, it remains unclear whether motor output variability or altered muscle activation impairs accuracy in women. Here, we examine sex differences in endpoint accuracy during ankle goal-directed movements and the activity of the antagonistic muscles. Ten women (23.1 ± 5.1 years) and 10 men (23 ± 3.7 years) aimed to match a target (9° in 180 ms) with ankle dorsiflexion. Participants performed 50 trials and we recorded the endpoint accuracy and the electromyographic (EMG) activity of the primary agonist (Tibialis Anterior; TA) and antagonist (Soleus; SOL) muscles. Women exhibited greater spatial inaccuracy (Position error: t = -2.65, P = 0.016) but not temporal inaccuracy relative to men. The motor output variability was similar for the two sexes (P > 0.2). The spatial inaccuracy in women was related to greater variability in the coordination of the antagonistic muscles (R 2 0.19, P = 0.03). These findings suggest that women are spatially less accurate than men during fast goal-directed movements likely due to an altered activation of the antagonistic muscles.

Can Noncardiac Syncope Occur during Exercise?

We describe the case of a 25-year-old athlete experiencing syncope during a 5-km running race. A thorough diagnostic workup reasonably excluded a cardiac disorder as the cause of syncope. The characterization of this episode of syncope as noncardiac appears to contradict the common belief that syncope during exercise has always a cardiac origin. Following a detailed history taking, it was revealed that the symptoms of the athlete started after a 180° turn of the route. This situation represents a setting relevant to a runner who stops suddenly after reaching the finish line and soon after experiences noncardiac syncope due to the abrupt cessation of muscle pump function of the lower limbs. Although the symptoms of the athlete in this report occurred during running, implying at a first glance the diagnosis of syncope occurring during exercise, a more detailed analysis of the circumstances indicated that these symptoms were in essence presenting after exercise from a pathophysiological view. The distinction between syncope occurring during and after exercise may be challenging enough for athletic activities involving a sudden stop of the running activity, such as for running races with sudden inversion of the route and sports characterized by rapid "starts and stops."