Small vessel disease disrupts EEG postural brain networks in 'unexplained dizziness in the elderly'.

OBJECTIVE: To examine the hypothesis that small vessel disease disrupts postural networks in older adults with unexplained dizziness in the elderly (UDE). METHODS: Simultaneous electroencephalography and postural sway measurements were undertaken in upright, eyes closed standing, and sitting postures (as baseline) in 19 younger adults, 33 older controls and 36 older patients with UDE. Older adults underwent magnetic resonance imaging to determine whole brain white matter hyperintensity volumes, a measure of small vessel disease. Linear regression was used to estimate the effect of instability on electroencephalographic power and connectivity. RESULTS: Ageing increased theta and alpha desynchronisation on standing. In older controls, delta and gamma power increased, and theta and alpha power reduced with instability. Dizzy older patients had higher white matter hyperintensity volumes and more theta desynchronisation during periods of instability. White matter hyperintensity volume and delta power during periods of instability were correlated, positively in controls but negatively in dizzy older patients. Delta power correlated with subjective dizziness and instability. CONCLUSIONS: Neural resource demands of postural control increase with age, particularly in patients with UDE, driven by small vessel disease. SIGNIFICANCE: EEG correlates of postural control saturate in older adults with UDE, offering a neuro-physiological basis to this common syndrome.

Time to consider the role of rationalisation in health psychology.

OBJECTIVE: The objective of this study was to determine the interaction between psychological factors, belief systems, and engagement around public health initiatives. STUDY DESIGN: We conducted a longitudinal observational study, utilising convenience sampling to examine illness-related perception in the immediate and medium-term stages of the first wave of the SARS-CoV-2 pandemic in the UK. METHODS: Weekly questionnaires assessed our primary measure, illness-related perception, using The Health Anxiety Inventory. Other psychological measures included apathy, loneliness, depersonalisation, state anxiety, trait anxiety as well as personality traits. Multiple regressions were performed to determine which psychological factors predicted the variance of health anxiety every week using the enter method. RESULTS: A combination of psychological variables that varied over time and were modulated by external events predicted the evolution of illness-related perception and associated aversion to perceived threat. CONCLUSION: Our findings highlight how in the face of a public health crisis, psychological factors play a determining role in the synthesis of beliefs as well as guiding human behaviour.

Subjective visual vertical and visual dependency in patients with multiple sclerosis.

BACKGROUND: Spatial orientation is an inherent ability governed by the complex integration of visual, vestibular and proprioceptive inputs. The degree to which an individual relies upon visual cues, as opposed to the vestibular or proprioceptive cues, is termed visual dependence. Although abnormal visual dependence has been documented in other neurological disorders, it is not known whether MS leads to visual dependence, and if so whether this is related to disease progression, clinical disability, or neuro-inflammatory burden in the central nervous system. OBJECTIVE: To evaluate SVV and visual dependence using a novel mobile virtual reality-based system for subjective visual vertical assessment (VIRVEST) and evaluate its relationship with the Expanded Disability Scale Score (EDSS), MS course and clinical findings. METHODS: The study included 59 patients with MS and 59 controls. Four tests were integrated in VIRVEST system and performed by each patient: a static SVV, dynamic SVV with clockwise and counter-clockwise background stimulus rotation, and SVV in a virtual reality background - a boat floating in the wavy water - to be adjusted vertically. Visual dependence was evaluated as a function of dynamic SVV. RESULTS: Patients with MS manifest larger biases in both static and dynamic SVV than healthy controls (p<0.001), in addition to higher visual dependence scores (p<0.05). MS patients with an EDSS score >4.5 had larger values of dynamic SVV and when compared to MS patients with lower EDSS scores (p<0.01), and visual dependence was related to disease severity. Patients with progressive MS disease course demonstrated statistically significantly larger dynamic SVV and visual dependence scores when compared to MS patients with relapsing-remitting disease (p<0.01). The mean System Usability Scores for the VIRVEST system corresponded to a patient perceived adjective rating of ``excellent''. CONCLUSION: We have evaluated the application of a novel virtual reality-based SVV test in patients with MS. We identified greater dynamic SVV errors suggestive of visual dependence in patients with MS versus controls and show that dynamic SVV abnormalities are related to disability measures. We suggest that this paradigm is effective at identifying visual dependence in neurological patients, and may have application in clinical settings, given high system usability scores.

Functional eye movement disorders.

Functional (psychogenic) eye movement disorders are perhaps less established in the medical literature than other types of functional movement disorders. Patients may present with ocular symptoms (e.g., blurred vision or oscillopsia) or functional eye movements may be identified during the formal examination of the eyes in patients with other functional disorders. Convergence spasm is the most common functional eye movement disorder, but functional gaze limitation, functional eye oscillations (also termed "voluntary nystagmus"), and functional convergence paralysis may be underreported. This chapter reviews the different types of functional eye movement abnormalities and provides a practical framework for their diagnosis and management.

Combining physical training with transcranial direct current stimulation to improve gait in Parkinson's disease: a pilot randomized controlled study.

OBJECTIVE: To improve gait and balance in patients with Parkinson's disease by combining anodal transcranial direct current stimulation with physical training. DESIGN: In a double-blind design, one group (physical training; n = 8) underwent gait and balance training during transcranial direct current stimulation (tDCS; real/sham). Real stimulation consisted of 15 minutes of 2 mA transcranial direct current stimulation over primary motor and premotor cortex. For sham, the current was switched off after 30 seconds. Patients received the opposite stimulation (sham/real) with physical training one week later; the second group (No physical training; n = 8) received stimulation (real/sham) but no training, and also repeated a sequential transcranial direct current stimulation session one week later (sham/real). SETTING: Hospital Srio Libanes, Buenos Aires, Argentina. SUBJECTS: Sixteen community-dwelling patients with Parkinson's disease. INTERVENTIONS: Transcranial direct current stimulation with and without concomitant physical training. MAIN MEASURES: Gait velocity (primary gait outcome), stride length, timed 6-minute walk test, Timed Up and Go Test (secondary outcomes), and performance on the pull test (primary balance outcome). RESULTS: Transcranial direct current stimulation with physical training increased gait velocity (mean = 29.5%, SD = 13; p < 0.01) and improved balance (pull test: mean = 50.9%, SD = 37; p = 0.01) compared with transcranial direct current stimulation alone. There was no isolated benefit of transcranial direct current stimulation alone. Although physical training improved gait velocity (mean = 15.5%, SD = 12.3; p = 0.03), these effects were comparatively less than with combined tDCS + physical therapy (p < 0.025). Greater stimulation-related improvements were seen in patients with more advanced disease. CONCLUSIONS: Anodal transcranial direct current stimulation during physical training improves gait and balance in patients with Parkinson's disease. Power calculations revealed that 14 patients per treatment arm (α = 0.05; power = 0.8) are required for a definitive trial.

Applying anodal tDCS during tango dancing in a patient with Parkinson's disease.

Gait disturbance in patients with Parkinson's disease remains a therapeutic challenge, given its poor response to levodopa. Dance therapy is of recognised benefit in these patients, particularly partnered dance forms such as the tango. In parallel, non-invasive brain stimulation has begun to show promise for the rehabilitation of patients with Parkinson's disease, although effects on gait, compared to upper limbs, have been less well defined. We applied transcranial direct current stimulation (tDCS) in a 79 year old male patient with moderate Parkinson's disease during tango dancing to assess its effect on trunk motion and balance. The patient performed a total of four dances over two days, two 'tango+tDCS' and two 'tango+sham' in a randomised double-blind fashion. In a separate experimental session we also assessed the isolated effect of tDCS (and sham) on gait without tango dancing. For the dance session, trunk peak velocity during tango was significantly greater during tDCS compared to sham stimulation. In the gait experiments we observed a modest but significant reduction in the time taken to complete the 3m 'timed up and go' and 6m walk, and an increase in overall gait velocity and peak pitch trunk velocity with tDCS compared to sham. Our findings suggest that tDCS may be a useful adjunct to gait rehabilitation for patients with PD, although studies in a larger group of patients are needed to evaluate the therapeutic use of non-invasive brain stimulation during dance therapy.

The effect of gait approach velocity on the broken escalator phenomenon.

Walking onto a stationary surface previously experienced as moving generates an after-effect commonly known as the "broken escalator" after-effect (AE). This AE represents an inappropriate expression of the locomotor adaptation necessary to step onto the moving platform (or escalator). It is characterised by two main biomechanical components, an increased gait approach velocity (GAV) and a forward trunk overshoot on gait termination. We investigated whether the trunk overshoot and other biomechanical measures are the direct inertial consequence of the increased GAV or whether these are the result of an independent adaptive mechanism. Forty-eight healthy young adults walked onto a movable sled. They performed 5 trials with the sled stationary at their preferred walking velocity (BEFORE trials), 5 with the sled moving (MOVING or adaptation trials), and 5 with the sled stationary again (AFTER trials). For the AFTER trials, subjects were divided into four groups. One group was instructed to walk slowly ("slower"), another with cueing at the BEFORE pace ("metronome"). The third group walked without cueing at the BEFORE pace ("normal"), and the fourth, fast ("faster"). We measured trunk pitch angle, trunk linear horizontal displacement, left shank pitch angular velocity and surface EMG from lower leg and trunk muscles. In the AFTER trials, an AE was observed in these biomechanical measures for all gait speeds, but these were not strongly dependent on GAV. An AE was present even when GAV was not different from that of BEFORE trials. Therefore, we conclude that, although contributary, the trunk overshoot is not the direct consequence of the increased GAV. Instead, it appears to be generated by anticipatory motor activity "just in case" the sled moves, herewith termed a "pre-emptive" postural adjustment.

Enhanced locomotor adaptation aftereffect in the "broken escalator" phenomenon using anodal tDCS.

The everyday experience of stepping onto a stationary escalator causes a stumble, despite our full awareness that the escalator is broken. In the laboratory, this "broken escalator" phenomenon is reproduced when subjects step onto an obviously stationary platform (AFTER trials) that was previously experienced as moving (MOVING trials) and attests to a process of motor adaptation. Given the critical role of M1 in upper limb motor adaptation and the potential for transcranial direct current stimulation (tDCS) to increase cortical excitability, we hypothesized that anodal tDCS over leg M1 and premotor cortices would increase the size and duration of the locomotor aftereffect. Thirty healthy volunteers received either sham or real tDCS (anodal bihemispheric tDCS; 2 mA for 15 min at rest) to induce excitatory effects over the primary motor and premotor cortex before walking onto the moving platform. The real tDCS group, compared with sham, displayed larger trunk sway and increased gait velocity in the first AFTER trial and a persistence of the trunk sway aftereffect into the second AFTER trial. We also used transcranial magnetic stimulation to probe changes in cortical leg excitability using different electrode montages and eyeblink conditioning, before and after tDCS, as well as simulating the current flow of tDCS on the human brain using a computational model of these different tDCS montages. Our data show that anodal tDCS induces excitability changes in lower limb motor cortex with resultant enhancement of locomotor adaptation aftereffects. These findings might encourage the use of tDCS over leg motor and premotor regions to improve locomotor control in patients with neurological gait disorders.

A new device to quantify ocular counterroll using retinal afterimages.

BACKGROUND: The integrity of vertical semicircular canal and otolith function remains difficult to assess in the clinical setting, partly due to difficulties in recording ocular counterroll. Here, we quantify static ocular counterroll from head tilt using a new head-mounted device. METHODS: The device consists of an LED positioned 42 cm in front of one eye and a striated lens which produces a streak of light on the retina. The LED is illuminated at full intensity (80 cd) to generate a retinal afterimage. Subsequently, in darkness, the subject's head is tilted in the roll plane. Finally, the LED is illuminated dimly (0.2 cd) and the subject rotates the striated lens to superimpose the dim light streak onto the afterimage. An angular scale indicates the angle through which the lens is rotated, giving a measure of the ocular counterroll. To validate the device, we recorded binocular counterroll simultaneously with 3D computerised video-oculography of the other eye in 16 normal subjects; 2 patients with acquired bilateral loss of vestibular function were also tested. RESULTS: In the normal subjects, there was no significant difference between the two techniques (p=0.24) when recording ocular counterroll and the correlation between the two techniques was R2=0.78. The 2 avestibular patients essentially showed no ocular counterroll with both techniques. CONCLUSIONS: We have devised a non-invasive, quick and reliable test of ocular counterroll. The lack of response in the 2 avestibular patients indicates that this device is clinically applicable to assess otolith function.

The effect of trial number on the emergence of the 'broken escalator' locomotor aftereffect.

Walking onto a stationary platform, which had been previously experienced as moving generates a locomotor aftereffect (LAE), which resembles the 'broken escalator' phenomenon. Experimentally, this is achieved by having subjects walk initially onto a stationary sled (BEFORE condition), then onto a moving sled (MOVING condition, or adaptation trials) and then again onto the stationary sled (AFTER condition). Subjects are always appropriately warned of the change in conditions. In this paper, we ask how many adaptation trials are needed to produce such a LAE. Thus, in two experiments, the number of MOVING trials was varied between 20 and 5 (Experiment 1) and between 8 and 1 (Experiment 2). Gait velocity, trunk position, foot contact timing and EMG of the ankle flexor-extensors muscles were measured. In comparison with BEFORE trials all groups in the AFTER trials walked inappropriately fast, experienced a large overshoot of the trunk and showed increased leg EMG, indicating that all groups showed a LAE. In each experiment, and for all variables, no significant difference between the groups (i.e. 20 down to one MOVING trials) was found. The study shows that this LAE, in contrast to other motor aftereffects reported in the literature, can be generated with only one or two adaptation trials and without requiring unexpected 'catch' trials. The fast aftereffect generation observed is likely to depend on two types of mechanisms: (1) the nature of the sensorimotor adaptation process, involving multiple sensory feedbacks (visual, vestibular and proprioceptive), anticipatory control and large initial task errors and (2) the involvement of two phylogenetically old neural mechanisms, namely locomotion and fear. Fear-relevant mechanisms, which are notably resistant to cognitive control, may be recruited during the adaptation trials and contribute to the release of this LAE.