Efectividad del trabajo de resistencia y de cicloergómetro a alta velocidad sobre la bradicinesia en la enfermedad de Parkinson: revisión sistemática / Effectiveness of endurance exercises and high-speed cycling on bradykinesia in Parkinson's disease: A systematic review

Antecedentes y objetivo Los ejercicios de resistencia y de cicloergómetro a alta intensidad se han utilizado en los últimos años para tratar la bradicinesia en la enfermedad de Parkinson (EP). El objetivo es determinar la efectividad del ejercicio de resistencia y de cicloergómetro a alta intensidad para disminuir la bradicinesia en pacientes con EP. Sujetos y métodos Se realizó una búsqueda hasta el año 2020 en las bases de datos PubMed, Web of Science, Medline, Cochrane Library, Google Scholar y ScienceDirect. Para evaluar la calidad metodológica y validez interna de los estudios se utilizó la escala PEDro. Resultados Se incluyeron 10 estudios en nuestra revisión. Cinco estudios llevaron a cabo un trabajo con cicloergómetro de alta intensidad cuya duración fue de una a cinco semanas, mejorando la bradicinesia cuatro de ellos, siendo tres de manera significativa. Cuatro estudios realizaron un trabajo con resistencia (desde nueve semanas hasta 24 meses) mejorando todos la bradicinesia, siendo significativos tres de ellos. Un estudio realizó un trabajo de resistencia y cicloergómetro demostrando mejorar la bradicinesia tras 12 semanas de tratamiento. Conclusión Aunque los dos tratamientos son beneficiosos para mejorar la bradicinesia en EP con severidades leves-moderadas, en un periodo mínimo de una semana, el tratamiento con cicloergómetro a alta velocidad tiene mejoras significativas, mientras que el trabajo con resistencia lo hace a partir de nueve semanas, siendo necesarios más estudios con mejores evidencias (AU)

Background and objective Endurance and high-intensity stationary cycling exercises have been used in recent years to treat bradykinesia in Parkinson's disease (PD). The aim is to determine the effectiveness of endurance and high-intensity stationary cycling in reducing bradykinesia in people with PD. Subjects and methods A search was conducted up to 2020 in the PubMed, Web of Science, Medline, Cochrane Library, Google Scholar and ScienceDirect databases. The PEDro scale was used to assess the methodological quality and internal validity of the studies. Results 10 studies were included in our review. Five studies carried out high intensity stationary cycling workouts with a duration of 1 to 5 weeks, 4 of them showed improved bradykinesia, 3 of them significantly. Four studies carried out endurance exercises (from 9 weeks to 24 months) all cases of bradykinesia improved, 3 significantly. One study looked at endurance exercises and stationary cycling showing, an improvement in bradykinesia after 12 weeks of treatment. Conclusion Although both treatments are beneficial for improving bradykinesia in PD of mild-moderate severity, in a minimum period of one week, treatment with high-speed stationary cycling shows significant improvements, while endurance exercises do so from 9 weeks onwards. Further studies with better evidence are needed (AU)

The effectiveness of peroneal nerve functional electrical simulation for the reduction of bradykinesia in Parkinson's disease: A feasibility study for a randomised control trial.

OBJECTIVES: To assess the feasibility of a multi-site randomised controlled trial to evaluate the effect of functional electrical stimulation on bradykinesia in people with Parkinson's disease. DESIGN: A two-arm assessor blinded randomised controlled trial with an 18 weeks intervention period and 4 weeks post-intervention follow-up. SETTING: Two UK hospitals; a therapy outpatient department in a district general hospital and a specialist neuroscience centre. PARTICIPANTS: A total of 64 participants with idiopathic Parkinson's disease and slow gait <1.25 ms-1. INTERVENTIONS: Functional electrical stimulation delivered to the common peroneal nerve while walking in addition to standard care compared with standard care alone. MAIN MEASURES: Feasibility aims included the determination of sample size, recruitment and retention rates, acceptability of the protocol and confirmation of the primary outcome measure. The outcome measures were 10 m walking speed, Unified Parkinson's Disease Rating Scale (UPDRS), Mini Balance Evaluation Systems Test, Parkinson's Disease Questionnaire-39, EuroQol 5-dimension 5-level, New Freezing of Gait questionnaire, Falls Efficacy Score International and falls diary. Participants opinion on the study design and relevance of outcome measures were evaluated using an embedded qualitative study. RESULTS: There was a mean difference between groups of 0.14 ms-1 (CI 0.03, 0.26) at week 18 in favour of the treatment group, which was maintained at week 22, 0.10 ms-1 (CI -0.05, 0.25). There was a mean difference in UPDRS motor examination score of -3.65 (CI -4.35, 0.54) at week 18 which was lost at week 22 -0.91 (CI -2.19, 2.26). CONCLUSION: The study design and intervention were feasible and supportive for a definitive trial. While both the study protocol and intervention were acceptable, recommendations for modifications are made.

Localization of motor and verbal fluency effects in subthalamic DBS for Parkinson's disease.

INTRODUCTION: Subthalamic nucleus deep brain stimulation (STN DBS) improves cardinal motor symptoms of Parkinson's disease (PD) but can worsen verbal fluency (VF). An optimal site of stimulation for overall motor improvement has been previously identified using an atlas-independent, fully individualized, field-modeling approach. This study examines if cardinal motor components (bradykinesia, tremor, and rigidity) share this identified optimal improvement site and if there is co-localization with a site that worsens VF. METHODS: An atlas-independent, field-modeling approach was used to identify sites of maximal STN DBS effect on overall and cardinal motor symptoms and VF in 60 patients. Anatomic coordinates were referenced to the STN midpoint. Symptom severity was assessed with the MDS-UPDRS part III and established VF scales. RESULTS: Sites for improved bradykinesia and rigidity co-localized with each other and the overall part III site (0.09 mm lateral, 0.93 mm posterior, 1.75 mm dorsal). The optimal site for tremor was posterior to this site (0.10 mm lateral, 1.40 mm posterior, 1.93 mm dorsal). Semantic and phonemic VF sites were indistinguishable and co-localized medial to the motor sites (0.32 mm medial, 1.18 mm posterior, 1.74 mm dorsal). CONCLUSION: This study identifies statistically distinct, maximally effective stimulation sites for tremor improvement, VF worsening, and overall and other cardinal motor improvements in STN DBS. Current electrode sizes and voltage settings stimulate all of these sites simultaneously. However, future targeted lead placement and focused directional stimulation may avoid VF worsening while maintaining motor improvements in STN DBS.

Progressive Resistance Training Improves Bradykinesia, Motor Symptoms and Functional Performance in Patients with Parkinson's Disease.

PURPOSE: Bradykinesia and muscle weaknesses are common symptoms of Parkinson's Disease (PD) and are associated with impaired functional performance, increased risk of falls, and reduced quality of life. Recent studies have pointed to progressive resistance training (PRT) as an effective method to control and reduce these symptoms, increasing possibilities to treat the disease. However, few studies have focused on assessing the PRT effects in the short-term. Therefore, the present study aimed to assess the short-term PRT effects on people with PD, in order to offer new parameters for a better understanding of its effects, so as an adequation and PRT use as a complementary therapy. PATIENTS AND METHODS: Forty individuals diagnosed with PD from stage 1 to 3 on the Hoehn and Yahr scale took part on the study and were allocated into 2 groups; Training Group (TG) performed a 9-week RT program twice a week, and the Control Group (CG) attended disease lectures. Bradykinesia UPDRS subscale (BSS), knee extensors isokinetic strength, Ten Meters Walk Test (TMW), Timed Up&Go Test (TUG) and 30-Second Chair Stand (T30) were measured before and after the intervention period. Statistical significance was set at p ≤ 0.05. RESULTS: Significant time was noted by the group interaction for all functional tests (TUG, T30, and TWM; all p < 0.01) and BSS (p < 0.01). Post hoc analyses revealed that these differences were driven by significant improvements in these dependent variables (all p < 0.01) while the CG remained unchanged (all p > 0.05). Moreover, TUG, T30, TWM, and BSS were significantly different between TG and CG in the post-training assessments (all p < 0.01). Isokinetic muscle strength was slightly increased in the TG (2.4%) and decreased in the CG (-2.2%), but statistical analyses did not reach significance for interaction but only a trend (p = 0.12). CONCLUSION: The results indicate that 9 weeks of PRT reduces bradykinesia and improves functional performance in patients with mild to moderate PD. These findings reinforce this mode of exercise as an important component of public health promotion programs for PD.

Personalized transcranial alternating current stimulation (tACS) and physical therapy to treat motor and cognitive symptoms in Parkinson's disease: A randomized cross-over trial.

Abnormal cortical oscillations are markers of Parkinson's Disease (PD). Transcranial alternating current stimulation (tACS) can modulate brain oscillations and possibly impact on behaviour. Mapping of cortical activity (prevalent oscillatory frequency and topographic scalp distribution) may provide a personalized neurotherapeutic target and guide non-invasive brain stimulation. This is a cross-over, double blinded, randomized trial. Electroencephalogram (EEG) from participants with PD referred to Specialist Clinic, University Hospital, were recorded. TACS frequency and electrode position were individually defined based on statistical comparison of EEG power spectra maps with normative data from our laboratory. Stimulation frequency was set according to the EEG band displaying higher power spectra (with beta excess on EEG map, tACS was set at 4 Hz; with theta excess, tACS was set at 30 Hz). Participants were randomized to tACS or random noise stimulation (RNS), 5 days/week for 2-weeks followed by ad hoc physical therapy. EEG, motor (Unified Parkinson's Disease Rating Scale-motor: UPDRS III), neuropsychological (frontal, executive and memory tests) performance and mood were measured before (T0), after (T1) and 4-weeks after treatment (T2). A linear model with random effects and Wilcoxon test were used to detect differences. Main results include a reduction of beta rhythm in theta-tACS vs. RNS group at T1 over right sensorimotor area (p = .014) and left parietal area (p = .010) and at T2 over right sensorimotor area (p = .004) and left frontal area (p = .039). Bradykinesia items improved at T1 (p = .002) and T2 (p = .047) compared to T0 in the tACS group. In the tACS group the Montréal Cognitive Assessment (MoCA) improved at T2 compared with T1 (p = .049). Individualized tACS in PD improves motor and cognitive performance. These changes are associated with a reduction of excessive fast EEG oscillations.

Efeito da técnica de sobrearticulação na voz e na fala em indivíduos com doença de Parkinson após cirurgia de estimulação cerebral profunda / Effect of overarticulation technique in voice and speech of individuals with Parkinson's disease with deep brain stimulation

RESUMO Objetivo Verificar o efeito imediato e após 15 minutos da técnica de sobrearticulação de fala em indivíduos com doença de Parkinson, submetidos à estimulação cerebral profunda em núcleo subtalâmico, nos parâmetros de voz, fala e mímica facial. Métodos Participaram 29 sujeitos com diagnóstico médico de doença de Parkinson, sob tratamento medicamentoso e submetidos à estimulação cerebral profunda em núcleo subtalâmico, com e sem reabilitação fonoaudiológica prévia. Realizou-se gravação em áudio e vídeo de amostra de fala e voz em três momentos: pré-intervenção, pós-imediato e após 15 minutos da realização individual de cinco minutos de uma sequência de exercícios de sobrearticulação de fala. As gravações foram submetidas à avaliação perceptivo-auditiva da voz e perceptivo-visual da mímica facial. Resultados A técnica produziu resultados positivos em 69% dos casos, após 15 minutos de aplicação, em relação aos demais momentos. O parâmetro que mais contribuiu para a identificação da melhor emissão na avaliação perceptivo-auditiva foi articulação (69%), significativamente maior que os demais parâmetros, exceto velocidade de fala. A análise perceptivo-visual mostrou melhora em 58,6% dos casos após 15 minutos, também significativamente melhor que os demais momentos. O parâmetro em que se observou maior proporção de melhora foi na movimentação de boca, sobrancelhas e olhos. Conclusão A técnica de sobrearticulação de fala produz efeito positivo imediato nos aspectos vocais e uma maior expressividade facial, principalmente após 15 minutos de realização.

ABSTRACT Purpose To verify the immediate and after 15 minutes effect of the overarticulation technique in individuals with Parkinson's disease, submitted to deep brain stimulation in subthalamic nucleus, in the voice, speech and facial movements. Methods This study counted with 29 patients with the diagnosis of Parkinson Disease who were undergoing pharmacotherapy and were submitted to deep brain stimulation in the subthalamic nucleus, with and without prior speech therapy. Speech and voice samples were recorded in an audio and video file at three different moments: pre-intervention, immediate post intervention and 15 minutes post intervention. The intervention was the individual performance of 5 minutes exercise consisting of sequence of overarticulation techniques. The audio and video recordings were submitted to the perceptual-judgement of the voice quality and facial movements. Results The technique produced positive results in 69% of the cases after 15 minutes of its application when compared to the other moments. Articulation was the parameter that most contributed in the perceptual-judgment of the best voice quality (69%); it was significantly higher than the other parameters, except speech rate. After 15 minutes of the technique, 58.6% of the patients had improvement in the facial movements, according to the perceptual-judgment which was also significantly better when compared to other moments. The parameter with greater provement was movement of the mouth, eyebrows and eyes. Conclusion The overarticulation technique produces an immediate positive effect on vocal aspects and greater facial expressiveness, especially after 15 minutes.

Realidad virtual como herramienta en fisioterapia, ¿ficción o realidad? / Virtual reality as a tool in physiotherapy: Fiction or reality?

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Game-Based Augmented Visual Feedback for Enlarging Speech Movements in Parkinson's Disease.

Purpose: The purpose of this pilot study was to demonstrate the effect of augmented visual feedback on acquisition and short-term retention of a relatively simple instruction to increase movement amplitude during speaking tasks in patients with dysarthria due to Parkinson's disease (PD). Method: Nine patients diagnosed with PD, hypokinetic dysarthria, and impaired speech intelligibility participated in a training program aimed at increasing the size of their articulatory (tongue) movements during sentences. Two sessions were conducted: a baseline and training session, followed by a retention session 48 hr later. At baseline, sentences were produced at normal, loud, and clear speaking conditions. Game-based visual feedback regarding the size of the articulatory working space (AWS) was presented during training. Results: Eight of nine participants benefited from training, increasing their sentence AWS to a greater degree following feedback as compared with the baseline loud and clear conditions. The majority of participants were able to demonstrate the learned skill at the retention session. Conclusions: This study demonstrated the feasibility of augmented visual feedback via articulatory kinematics for training movement enlargement in patients with hypokinesia due to PD. Supplemental Materials: https://doi.org/10.23641/asha.5116840.

Progressive resistance exercise restores some properties of the triphasic EMG pattern and improves bradykinesia: the PRET-PD randomized clinical trial.

In Parkinson's disease (PD), the characteristic triphasic agonist and antagonist muscle activation pattern during ballistic movement is impaired: the number of agonist muscle bursts is increased, and the amplitudes of the agonist and antagonist bursts are reduced. The breakdown of the triphasic electromyographic (EMG) pattern has been hypothesized to underlie bradykinesia in PD. Progressive resistance exercise has been shown to improve clinical measures of bradykinesia, but it is not clear whether the benefits for bradykinesia are accompanied by changes in agonist and antagonist muscle activity. This study examined the spatiotemporal changes in agonist and antagonist muscle activity following 24 mo of progressive resistance exercise and the combined relationship between spatiotemporal muscle activity and strength measures and upper limb bradykinesia. We compared the effects of progressive resistance exercise training (PRET) with a nonprogressive exercise intervention, modified Fitness Counts (mFC), in patients with PD. We randomized 48 participants with mild-to-moderate PD to mFC or PRET. At the study endpoint of 24 mo, participants randomized to PRET compared with mFC had significantly faster movement velocity, accompanied by significant increases in the duration, magnitude, and magnitude normalized to duration of the 1st agonist burst and fewer number of agonist bursts before peak velocity. The antagonist muscle activity was increased relative to baseline but did not differ between groups. Spatiotemporal EMG muscle activity and muscle strength were significantly associated with upper limb bradykinesia. These findings demonstrate that progressive resistance exercise improves upper limb movement velocity and restores some aspects of the triphasic EMG pattern.

Hypokinetic gait changes induced by bilateral pallidal deep brain stimulation for segmental dystonia.

BACKGROUND: Deep brain stimulation (DBS) of the globus pallidus internus (GPi) has been established as an effective and safe treatment for dystonia. In general, side effects are rare, but there is increasing evidence that GPi DBS in dystonia can induce hypokinetic symptoms like micrographia or freezing of gait. We aimed to evaluate and quantify possible changes of gait following bilateral chronic GPi DBS for dystonia by computerized gait analyses. METHODS: We prospectively performed computerized gait analysis in ten consecutive patients (mean age 57.8+/-14.3 years) with segmental dystonia but without involvement of lower trunk or legs who were treated with bilateral GPi DBS. Using pressure sensitive insoles, several parameters were measured preoperatively (pre-OP) and at a median of 7 months postoperatively. RESULTS: The mean step length significantly decreased from 60.0+/-6.9cm pre-OP to 54.3+/-6.4cm with GPi DBS (p<0.01). Due to only small changes of walking distance and gait velocity, the cadence correspondingly increased from 105.6+/-9.2 steps/min to 111.3+/-11.4 steps/min (p<0.05). More importantly, the variance of several gait parameters significantly decreased postoperatively. CONCLUSIONS: In patients with segmental dystonia, chronic DBS of the posteroventral lateral GPi is associated with only mild hypokinesia of gait, but with a relevant decrease in gait variability. Given other recently reported hypokinetic effects of GPi DBS for dystonia and recent results of electrophysiological coherence studies, these findings support the hypothesis of a general alteration of neuronal activity in striato-pallido-thalamo-cortical motor pathways following chronic stimulation of the posteroventral lateral GPi.

Transcranial Direct Current Stimulation to Enhance Dual-Task Gait Training in Parkinson's Disease: A Pilot RCT.

OBJECTIVE: To investigate the feasibility and safety of a combined anodal transcranial direct current stimulation (tDCS) and dual task gait training intervention in people with Parkinson's Disease (PD) and to provide data to support a sample size calculation for a fully powered trial should trends of effectiveness be present. DESIGN: A pilot, randomized, double-blind, sham-controlled parallel group trial with 12 week follow-up. SETTING: A university physiotherapy department. INTERVENTIONS: Sixteen participants diagnosed with PD received nine dual task gait training sessions over 3 weeks. Participants were randomized to receive either active or sham tDCS applied for the first 20 minutes of each session. MAIN MEASURES: The primary outcome was gait speed while undertaking concurrent cognitive tasks (word lists, counting, conversation). Secondary measures included step length, cadence, Timed Up and Go, bradykinesia and motor speed. RESULTS: Gait speed, step length and cadence improved in both groups, under all dual task conditions. This effect was maintained at follow-up. There was no difference between the active and sham tDCS groups. Time taken to perform the TUGwords also improved, with no difference between groups. The active tDCS group did however increase their correct cognitive response rate during the TUGwords and TUGcount. Bradykinesia improved after training in both groups. CONCLUSION: Three weeks of dual task gait training resulted in improved gait under dual task conditions, and bradykinesia, immediately following training and at 12 weeks follow-up. The only parameter enhanced by tDCS was the number of correct responses while performing the dual task TUG. tDCS applied to M1 may not be an effective adjunct to dual task gait training in PD. TRIAL REGISTRATION: Australia-New Zealand Clinical Trials Registry ACTRN12613001093774.

Power training induced change in bradykinesia and muscle power in Parkinson's disease.

UNLABELLED: Power-based resistance training (PWT), using low load and high velocity, can improve physical function and quality of life in older persons. Patients with Parkinson's disease (PD), exhibiting muscular weakness and reduced movement speed, have been shown to be benefit from resistance training; however, little is known about the advantages of PWT for PD. PURPOSE: To evaluate the effects of PWT on bradykinesia and muscular performance in older patients with PD. METHODS: Twenty-six patients with mild to moderate PD were randomly assigned to a PWT or control group (CON). The PWT program was three months, incorporating two sessions/wk of high-speed resistance training combined balance and agility drills. Outcome measures included: upper and lower limb bradykinesia scores, one repetition maximums (1RM) and peak powers on biceps curl, chest press, leg press, hip abduction and seated calf, and quality of life (PDQ-39). RESULTS: The PWT group produced significant improvement in both upper and lower limbs bradykinesia scores, 1RM and muscle peak power (p < .05), which surpassed the CON group except for power during the seated calf exercise. No significant correlations between changes in clinical measure of bradykinesia and muscle peak power were observed after training. Significant improvements were seen in the PDQ-39 overall score, subsections for mobility, activities of daily living and social support for the PWT group. CONCLUSION: The 3-month PWT program significantly reduced bradykinesia and increased muscle strength and power in older patients with PD. Power training is an effective training modality to improve physical function and quality of life for PD.

Adaptive training with full-body movements to reduce bradykinesia in persons with Parkinson's disease: a pilot study.

BACKGROUND: Bradykinesia (slow movements) is a common symptom of Parkinson's disease (PD) and results in reduced mobility and postural instability. The objective of this study is to develop and demonstrate a technology-assisted exercise protocol that is specifically aimed at reducing bradykinesia. METHODS: Seven persons with PD participated in this study. They were required to perform whole body reaching movements toward targets placed in different directions and at different elevations. Movements were recorded by a Microsoft Kinect movement sensor and used to control a human-like avatar, which was continuously displayed on a screen placed in front of the subjects. After completion of each movement, subjects received a 0-100 score that was inversely proportional to movement time. Target distance in the next movements was automatically adjusted in order to keep the score around a pre-specified target value. In this way, subjects always exercised with the largest movement amplitude they could sustain. The training protocol was organised into blocks of 45 movements toward targets placed in three different directions and at three different elevations (a total of nine targets). Each training session included a finite number of blocks, fitted within a fixed 40 minutes duration. The whole protocol included a total of 10 sessions (approximately two sessions/week). As primary outcome measure we took the absolute average acceleration. Various aspects of movement performance were taken as secondary outcome measures, namely accuracy (undershoot error), path curvature, movement time, and average speed. RESULTS: Throughout sessions, we observed an increase of the absolute average acceleration and speed and decreased undershoot error and movement time. Exercise also significantly affected the relationship between target elevation and both speed and acceleration - the improvement was greater at higher elevations. CONCLUSIONS: The device and the protocol were well accepted by subjects and appeared safe and easy to use. Our preliminary results point at a training-induced reduction of bradykinesia.

Vagus nerve stimulation delivered during motor rehabilitation improves recovery in a rat model of stroke.

Neural plasticity is widely believed to support functional recovery following brain damage. Vagus nerve stimulation paired with different forelimb movements causes long-lasting map plasticity in rat primary motor cortex that is specific to the paired movement. We tested the hypothesis that repeatedly pairing vagus nerve stimulation with upper forelimb movements would improve recovery of motor function in a rat model of stroke. Rats were separated into 3 groups: vagus nerve stimulation during rehabilitation (rehab), vagus nerve stimulation after rehab, and rehab alone. Animals underwent 4 training stages: shaping (motor skill learning), prelesion training, postlesion training, and therapeutic training. Rats were given a unilateral ischemic lesion within motor cortex and implanted with a left vagus nerve cuff. Animals were allowed 1 week of recovery before postlesion baseline training. During the therapeutic training stage, rats received vagus nerve stimulation paired with each successful trial. All 17 trained rats demonstrated significant contralateral forelimb impairment when performing a bradykinesia assessment task. Forelimb function was recovered completely to prelesion levels when vagus nerve stimulation was delivered during rehab training. Alternatively, intensive rehab training alone (without stimulation) failed to restore function to prelesion levels. Delivering the same amount of stimulation after rehab training did not yield improvements compared with rehab alone. These results demonstrate that vagus nerve stimulation repeatedly paired with successful forelimb movements can improve recovery after motor cortex ischemia and may be a viable option for stroke rehabilitation.

Time to get a move on: overcoming bradykinetic movement in Parkinson's disease with artificial sensory guidance generated from biological motion.

Paradoxical kinesia describes the motor improvement in Parkinson's disease (PD) triggered by the presence of external sensory information relevant for the movement. This phenomenon has been puzzling scientists for over 60 years, both in neurological and motor control research, with the underpinning mechanism still being the subject of fierce debate. In this paper we present novel evidence supporting the idea that the key to understanding paradoxical kinesia lies in both spatial and temporal information conveyed by the cues and the coupling between perception and action. We tested a group of 7 idiopathic PD patients in an upper limb mediolateral movement task. Movements were performed with and without a visual point light display, travelling at 3 different speeds. The dynamic information presented in the visual point light display depicted three different movement speeds of the same amplitude performed by a healthy adult. The displays were tested and validated on a group of neurologically healthy participants before being tested on the PD group. Our data show that the temporal aspects of the movement (kinematics) in PD can be moderated by the prescribed temporal information presented in a dynamic environmental cue. Patients demonstrated a significant improvement in terms of movement time and peak velocity when executing movement in accordance with the information afforded by the point light display, compared to when the movement of the same amplitude and direction was performed without the display. In all patients we observed the effect of paradoxical kinesia, with a strong relationship between the perceptual information prescribed by the biological motion display and the observed motor performance of the patients.

Reduction of bradykinesia of finger movements by a single session of action observation in Parkinson disease.

BACKGROUND: Action observation influences motor performance in healthy subjects and persons with motor impairments. OBJECTIVE: To understand the effects of action observation on the spontaneous rate of finger movements in patients with Parkinson disease (PD). METHODS: Participants, 20 with PD and 14 healthy controls, were randomly divided into 2 groups. Those in the VIDEO group watched video clips showing repetitive finger movements paced at 3 Hz, whereas those in the ACOUSTIC group listened to an acoustic cue paced at 3 Hz. All participants performed a finger sequence at their spontaneous pace at different intervals (before, at the end of, 45 minutes after, and 2 days after training); 8 participants with PD were recruited for a sham intervention, watching a 6-minute video representing a static hand. Finally, 10 patients participated in the same protocol used for the VIDEO group but were tested in the on and off medication states. RESULTS: Both VIDEO and ACOUSTIC training increased the spontaneous rate in all participants. VIDEO intervention showed a greater effect over time, improving the spontaneous rate and reducing the intertapping interval to a larger extent than ACOUSTIC 45 minutes and 2 days after training. Action observation significantly influenced movement rate in on and off conditions, but 45 minutes after training, the effect was still present only in the on condition. No effect was observed after sham intervention. CONCLUSIONS: These findings suggest that the dopaminergic state contributes to the effects of action observation, and this training may be a promising approach in the rehabilitation of bradykinesia in PD.

Active-assisted cycling improves tremor and bradykinesia in Parkinson's disease.

OBJECTIVES: To develop a rapid cadence cycling intervention (active-assisted cycling [AAC]) using a motorized bike and to examine physiological perimeters during these sessions in individuals with Parkinson's disease (PD). A secondary goal was to examine whether a single session of AAC at a high cadence would promote improvements in tremor and bradykinesia similar to the on medication state. DESIGN: Before-after pilot trial with cross-over. SETTING: University research laboratory. PARTICIPANTS: Individuals with idiopathic PD (N=10, age 45-74y) in Hoehn and Yahr stages 1 to 3. INTERVENTION: Forty minutes of AAC. MAIN OUTCOME MEASURES: Heart rate, pedaling power, and rating of perceived exertion were recorded before, during, and after a bout of AAC. Functional assessments included tremor score during resting, postural, and kinetic tremor. RESULTS: This AAC paradigm was well tolerated by individuals with PD without excessive fatigue, and most participants showed improvements in tremor and bradykinesia immediately after a single bout of cycling. CONCLUSIONS: This paradigm could be used to examine changes in motor function in individuals with PD after bouts of high-intensity exercise.

Controlled study of 50-Hz repetitive transcranial magnetic stimulation for the treatment of Parkinson disease.

OBJECTIVE: To investigate the safety and efficacy of 50-Hz repetitive transcranial magnetic stimulation (rTMS) in the treatment of motor symptoms in Parkinson disease (PD). BACKGROUND: Progression of PD is characterized by the emergence of motor deficits that gradually respond less to dopaminergic therapy. rTMS has shown promising results in improving gait, a major cause of disability, and may provide a therapeutic alternative. Prior controlled studies suggest that an increase in stimulation frequency might enhance therapeutic efficacy. METHODS: In this randomized, double blind, sham-controlled study, the authors investigated the safety and efficacy of 50-Hz rTMS of the motor cortices in 8 sessions over 2 weeks. Assessment of safety and clinical efficacy over a 1-month period included timed tests of gait and bradykinesia, Unified Parkinson's Disease Rating Scale (UPDRS), and additional clinical, neurophysiological, and neuropsychological parameters. In addition, the safety of 50-Hz rTMS was tested with electromyography-electroencephalogram (EMG-EEG) monitoring during and after stimulation. RESULTS: The authors investigated 26 patients with mild to moderate PD: 13 received 50-Hz rTMS and 13 sham stimulation. The 50-Hz rTMS did not improve gait, bradykinesia, and global and motor UPDRS, but there appeared a short-lived "on"-state improvement in activities of daily living (UPDRS II). The 50-Hz rTMS lengthened the cortical silent period, but other neurophysiological and neuropsychological measures remained unchanged. EMG/EEG recorded no pathological increase of cortical excitability or epileptic activity. There were no adverse effects. CONCLUSION: It appears that 50-Hz rTMS of the motor cortices is safe, but it fails to improve motor performance and functional status in PD. Prolonged stimulation or other techniques with rTMS might be more efficacious but need to be established in future research.

Neural targets for relieving parkinsonian rigidity and bradykinesia with pallidal deep brain stimulation.

Clinical evidence has suggested that subtle changes in deep brain stimulation (DBS) settings can have differential effects on bradykinesia and rigidity in patients with Parkinson's disease. In this study, we first investigated the degree of improvement in bradykinesia and rigidity during targeted globus pallidus DBS in three 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated rhesus macaques. Behavioral outcomes of DBS were then coupled with detailed, subject-specific computational models of neurons in the globus pallidus internus (GPi), globus pallidus externus (GPe), and internal capsule (IC) to determine which neuronal pathways when modulated with high-frequency electrical stimulation best correlate with improvement in motor symptoms. The modeling results support the hypothesis that multiple neuronal pathways can underlie the therapeutic effect of DBS on parkinsonian bradykinesia and rigidity. Across all three subjects, improvements in rigidity correlated most strongly with spread of neuronal activation into IC, driving a small percentage of fibers within this tract (<10% on average). The most robust effect on bradykinesia resulted from stimulating a combination of sensorimotor axonal projections within the GP, specifically at the site of the medial medullary lamina. Thus the beneficial effects of pallidal DBS for parkinsonian symptoms may occur from multiple targets within and near the target nucleus.