O comportamento clínico e neurofisiológico da neuropatia durante os episódios reacionais da hanseníase

A hanseníase, uma doença conhecida por suas lesões de pele anestésicas, é a principal causa de neuropatia periférica nos países endêmicos. Os episódios reacionais são classicamente conhecidos por promover piora da função nervosa através das chamadas neurites que variam de quadros exuberantes a assintomáticos. Estas características da neuropatia tornam o diagnóstico precoce excepcionalmente desafiador assim como a necessidade de se intervir para se prevenir lesões permanentes nos nervos. Este estudo clínico, prospectivo, foi realizado selecionando-se pacientes com hanseníase, independente da forma clínica, no Ambulatório Souza Araujo, Fiocruz, Rio de Janeiro, que apresentavam episódios reacionais. O objetivo foi estudar o perfil neurológico clínico, eletroneurofisiológico e por imagem do nervo antes e após o tratamento das reações. Foram avaliados vinte e cinco pacientes levando-se em conta: exame neurológico, avaliação fisioterápica, estudo de condução nervosa, avaliação de espessura e ecogenicidade nervosa pelo método ultrassonográfico, fluxometria por laser Doppler e teste quantitativo da sensibilidade durante e um ano após o tratamento da reação. Estes pacientes foram divididos em três grupos: oito pacientes com neurite aguda, nove pacientes com neurite silenciosa e oito pacientes com reação cutânea sem neurite. Nos pacientes com episódios reacionais, observou-se predomínio do sexo masculino (60%), do grupo multibacilar (80%) e da forma clínica borderline-lepromatosa (36%). A neurite isolada foi o tipo de reação mais frequente, seguida de neurite associada à reação do tipo1, seguida da neurite associada à reação do tipo 2. O nervo motor mais acometido por neurite foi o fibular seguido pelo ulnar, enquanto o nervo sensitivo mais acometido foi o sural. O padrão eletroneuromiográfico característico dos episódios reacionais foi a mononeurite múltipla. A ultrassonografia, a fluxometria por laser Doppler e o teste quantitativo de sensibilidade, associados à clínica e ao estudo da condução nervosa, foram tidos como exames úteis para avaliação inicial e para acompanhar o tratamento dos episódios reacionais. Após o tratamento, foi constatada melhora nos parâmetros referentes à função motora, mas o mesmo não ocorreu para sensibilidade. Com esse estudo, observa-se a necessidade de acompanhamento multidiciplinar com exames especializados para os pacientes com hanseníase a fim de diagnóstico de reação e tratamento precoce evitando sequelas neurológicas.

Indicadores de neuropatia autonômica cardiovascular em pacientes com diabetes tipo 1

A Neuropatia autonômica cardiovascular (NAC), apesar de ter sido apontada como fator de risco independente para doença cardiovascular (DCV) em pacientes com diabetes tipo 1 (DM1), permanece subdiagnosticada. Os objetivos do trababalho foram determinar a prevalência de NAC e seus indicadores clínicos e laboratoriais em pacientes com DM1 e a associação com outras complicações crônicas do diabetes, além de avaliar a concordância entre os critérios diagnósticos da NAC determinados pelos parâmetros da análise espectral e pelos testes reflexos cardiovasculares. Pacientes com DM1, duração da doença ≥ 5 anos e com idade ≥ 13 anos foram submetidos a um questionário clínico-epidemiológico, a coleta de sangue e de urina para determinação da concentração urinária de albumina, ao mapeamento de retina, e exame clínico para pesquisa de neuropatia diabética sensitivo motora além da realização de testes reflexos cardiovasculares. Cento e cinquenta e um pacientes com DM1, 53.6 % do sexo feminino, 45.7% brancos, com média de idade de 33.4 13 anos, idade ao diagnóstico de 17.2 9.8 anos, duração de DM1 de 16.3 9.5 anos, índice de massa corporal (IMC) de 23.4 (13.7-37.9) Kg/m2 e níveis de hemoglobina glicada de 9.1 2% foram avaliados. Após realização dos testes para rastreamento das complicações microvasculares, encontramos neuropatia diabética sensitivo motora, retinopatia diabética, nefropatia diabética e NAC em 44 (29.1%), 54 (38%), 35 (24.1%) e 46 (30.5%) dos pacientes avaliados, respectivamente. A presença de NAC foi associada com idade (p=0.01), duração do DM (p=0.036), HAS (p=0.001), frequência cardíaca em repouso (p=0.000), HbA1c (p=0.048), uréia (p=0.000), creatinina (p=0.008), taxa de filtração glomerular (p=0.000), concentração urinária de albumina (p=0.000), níveis séricos de LDL-colesterol (p=0.048), T4 livre (p=0.023) e hemoglobina (p=0.01) e a presença de retinopatia (p=0.000), nefropatia (p=0.000) e neuropatia diabética sensitivo motora (p=0.000), além dos seguintes sintomas; lipotimia (p=0.000), náuseas pós alimentares (p=0.042), saciedade precoce (p=0.031), disfunção sexual (p=0.049) e sudorese gustatória (p=0.018). No modelo de regressão logística binária, avaliando o diagnóstico de NAC como variável dependente, foi observado que apenas a FC em repouso, presença de neuropatia diabética sensitivo motora e retinopatia diabética foram consideradas variáveis independentes significativamente. A NAC é uma complicação crônica comum do DM1, atingindo cerca de 30% dos pacientes estudados e encontra-se associada à presença de outras complicações da doença. Indicadores da presença de NAC nos pacientes avaliados incluíram a idade, duração do diabetes, presença de HAS, frequência cardíaca de repouso e presença de sintomas sugestivos de neuropatia autonômica. O presente estudo ratifica a importância do rastreamento sistemático e precoce desta complicação.

Motor learning.

Although learning a motor skill, such as a tennis stroke, feels like a unitary experience, researchers who study motor control and learning break the processes involved into a number of interacting components. These components can be organized into four main groups. First, skilled performance requires the effective and efficient gathering of sensory information, such as deciding where and when to direct one's gaze around the court, and thus an important component of skill acquisition involves learning how best to extract task-relevant information. Second, the performer must learn key features of the task such as the geometry and mechanics of the tennis racket and ball, the properties of the court surface, and how the wind affects the ball's flight. Third, the player needs to set up different classes of control that include predictive and reactive control mechanisms that generate appropriate motor commands to achieve the task goals, as well as compliance control that specifies, for example, the stiffness with which the arm holds the racket. Finally, the successful performer can learn higher-level skills such as anticipating and countering the opponent's strategy and making effective decisions about shot selection. In this Primer we shall consider these components of motor learning using as an example how we learn to play tennis.

Context-dependent partitioning of motor learning in bimanual movements.

Human subjects easily adapt to single dynamic or visuomotor perturbations. In contrast, when two opposing dynamic or visuomotor perturbations are presented sequentially, interference is often observed. We examined the effect of bimanual movement context on interference between opposing perturbations using pairs of contexts, in which the relative direction of movement between the two arms was different across the pair. When each perturbation direction was associated with a different bimanual context, such as movement of the arms in the same direction versus movement in the opposite direction, interference was dramatically reduced. This occurred over a short period of training and was seen for both dynamic and visuomotor perturbations, suggesting a partitioning of motor learning for the different bimanual contexts. Further support for this was found in a series of transfer experiments. Having learned a single dynamic or visuomotor perturbation in one bimanual context, subjects showed incomplete transfer of this learning when the context changed, even though the perturbation remained the same. In addition, we examined a bimanual context in which one arm was moved passively and show that the reduction in interference requires active movement. The sensory consequences of movement are thus insufficient to allow opposing perturbations to be co-represented. Our results suggest different bimanual movement contexts engage at least partially separate representations of dynamics and kinematics in the motor system.

Human muscle spindles act as forward sensory models.

Modern theories of motor control incorporate forward models that combine sensory information and motor commands to predict future sensory states. Such models circumvent unavoidable neural delays associated with on-line feedback control. Here we show that signals in human muscle spindle afferents during unconstrained wrist and finger movements predict future kinematic states of their parent muscle. Specifically, we show that the discharges of type Ia afferents are best correlated with the velocity of length changes in their parent muscles approximately 100-160 ms in the future and that their discharges vary depending on motor sequences in a way that cannot be explained by the state of their parent muscle alone. We therefore conclude that muscle spindles can act as "forward sensory models": they are affected both by the current state of their parent muscle and by efferent (fusimotor) control, and their discharges represent future kinematic states. If this conjecture is correct, then sensorimotor learning implies learning how to control not only the skeletal muscles but also the fusimotor system.

Statistics of natural movements are reflected in motor errors.

Humans use their arms to engage in a wide variety of motor tasks during everyday life. However, little is known about the statistics of these natural arm movements. Studies of the sensory system have shown that the statistics of sensory inputs are key to determining sensory processing. We hypothesized that the statistics of natural everyday movements may, in a similar way, influence motor performance as measured in laboratory-based tasks. We developed a portable motion-tracking system that could be worn by subjects as they went about their daily routine outside of a laboratory setting. We found that the well-documented symmetry bias is reflected in the relative incidence of movements made during everyday tasks. Specifically, symmetric and antisymmetric movements are predominant at low frequencies, whereas only symmetric movements are predominant at high frequencies. Moreover, the statistics of natural movements, that is, their relative incidence, correlated with subjects' performance on a laboratory-based phase-tracking task. These results provide a link between natural movement statistics and motor performance and confirm that the symmetry bias documented in laboratory studies is a natural feature of human movement.

Task-dependent coordination of rapid bimanual motor responses.

Optimal feedback control postulates that feedback responses depend on the task relevance of any perturbations. We test this prediction in a bimanual task, conceptually similar to balancing a laden tray, in which each hand could be perturbed up or down. Single-limb mechanical perturbations produced long-latency reflex responses ("rapid motor responses") in the contralateral limb of appropriate direction and magnitude to maintain the tray horizontal. During bimanual perturbations, rapid motor responses modulated appropriately depending on the extent to which perturbations affected tray orientation. Specifically, despite receiving the same mechanical perturbation causing muscle stretch, the strongest responses were produced when the contralateral arm was perturbed in the opposite direction (large tray tilt) rather than in the same direction or not perturbed at all. Rapid responses from shortening extensors depended on a nonlinear summation of the sensory information from the arms, with the response to a bimanual same-direction perturbation (orientation maintained) being less than the sum of the component unimanual perturbations (task relevant). We conclude that task-dependent tuning of reflexes can be modulated online within a single trial based on a complex interaction across the arms.

Motor control is decision-making.

Motor behavior may be viewed as a problem of maximizing the utility of movement outcome in the face of sensory, motor and task uncertainty. Viewed in this way, and allowing for the availability of prior knowledge in the form of a probability distribution over possible states of the world, the choice of a movement plan and strategy for motor control becomes an application of statistical decision theory. This point of view has proven successful in recent years in accounting for movement under risk, inferring the loss function used in motor tasks, and explaining motor behavior in a wide variety of circumstances.

The effect of contextual cues on the encoding of motor memories.

Several studies have shown that sensory contextual cues can reduce the interference observed during learning of opposing force fields. However, because each study examined a small set of cues, often in a unique paradigm, the relative efficacy of different sensory contextual cues is unclear. In the present study we quantify how seven contextual cues, some investigated previously and some novel, affect the formation and recall of motor memories. Subjects made movements in a velocity-dependent curl field, with direction varying randomly from trial to trial but always associated with a unique contextual cue. Linking field direction to the cursor or background color, or to peripheral visual motion cues, did not reduce interference. In contrast, the orientation of a visual object attached to the hand cursor significantly reduced interference, albeit by a small amount. When the fields were associated with movement in different locations in the workspace, a substantial reduction in interference was observed. We tested whether this reduction in interference was due to the different locations of the visual feedback (targets and cursor) or the movements (proprioceptive). When the fields were associated only with changes in visual display location (movements always made centrally) or only with changes in the movement location (visual feedback always displayed centrally), a substantial reduction in interference was observed. These results show that although some visual cues can lead to the formation and recall of distinct representations in motor memory, changes in spatial visual and proprioceptive states of the movement are far more effective than changes in simple visual contextual cues.

Motor control is decision-making

© 2012 Elsevier Ltd. Motor behavior may be viewed as a problem of maximizing the utility of movement outcome in the face of sensory, motor and task uncertainty. Viewed in this way, and allowing for the availability of prior knowledge in the form of a probability distribution over possible states of the world, the choice of a movement plan and strategy for motor control becomes an application of statistical decision theory. This point of view has proven successful in recent years in accounting for movement under risk, inferring the loss function used in motor tasks, and explaining motor behavior in a wide variety of circumstances.

Motor effort alters changes of mind in sensorimotor decision making.

After committing to an action, a decision-maker can change their mind to revise the action. Such changes of mind can even occur when the stream of information that led to the action is curtailed at movement onset. This is explained by the time delays in sensory processing and motor planning which lead to a component at the end of the sensory stream that can only be processed after initiation. Such post-initiation processing can explain the pattern of changes of mind by asserting an accumulation of additional evidence to a criterion level, termed change-of-mind bound. Here we test the hypothesis that physical effort associated with the movement required to change one's mind affects the level of the change-of-mind bound and the time for post-initiation deliberation. We varied the effort required to change from one choice target to another in a reaching movement by varying the geometry of the choice targets or by applying a force field between the targets. We show that there is a reduction in the frequency of change of mind when the separation of the choice targets would require a larger excursion of the hand from the initial to the opposite choice. The reduction is best explained by an increase in the evidence required for changes of mind and a reduced time period of integration after the initial decision. Thus the criteria to revise an initial choice is sensitive to energetic costs.

Self-organization of reflexive behavior from spontaneous motor activity.

In mammals, the development of reflexes is often regarded as an innate process. However, recent findings show that fetuses are endowed with favorable conditions for ontogenetic development. In this article, we hypothesize that the circuitry of at least some mammalian reflexes can be self-organized from the sensory and motor interactions brought forth in a musculoskeletal system. We focus mainly on three reflexes: the myotatic reflex, the reciprocal inhibition reflex, and the reverse myotatic reflex. To test our hypothesis, we conducted a set of experiments on a simulated musculoskeletal system using pairs of agonist and antagonist muscles. The reflex connectivity is obtained by producing spontaneous motor activity in each muscle and by correlating the resulting sensor and motor signals. Our results show that, under biologically plausible conditions, the reflex circuitry thus obtained is consistent with that identified in relation to the analogous mammalian reflexes. In addition, they show that the reflex connectivity obtained depends on the morphology of the musculoskeletal system as well as on the environment that it is embedded in.

Growth of Motor Coordination in Early Robot Learning

M. H. Lee and Q. Meng, Growth of Motor Coordination in Early Robot Learning, IJCAI-05, 2005.

Staged development of Robot Motor Coordination

M.H. Lee and Q. Meng, 'Staged development of Robot Motor Coordination', IEEE International Conference on Systems, Man and Cybernetics, (IEEE SMC 05), Hawaii, USA, v3, 2917-2922, 2005.

Cerebellar Learning in an Opponent Motor Controller for Adaptive Load Compensation and Synergy Formation

This paper shows how a minimal neural network model of the cerebellum may be embedded within a sensory-neuro-muscular control system that mimics known anatomy and physiology. With this embedding, cerebellar learning promotes load compensation while also allowing both coactivation and reciprocal inhibition of sets of antagonist muscles. In particular, we show how synaptic long term depression guided by feedback from muscle stretch receptors can lead to trans-cerebellar gain changes that are load-compensating. It is argued that the same processes help to adaptively discover multi-joint synergies. Simulations of rapid single joint rotations under load illustrates design feasibility and stability.