Efeitos do treino em esteira na marcha com dupla tarefa de indivíduos com doença de Parkinson: ensaio clínico controlado randomizado

Background: The gait automaticity loss difficults realization of concurrent activities - Dual Task (DT). In these situations, individuals with Parkinson`s disease (PD) show a significant reduction in gait velocity and stride length, as strides variability and asymmetry increased, factors predisposing to falls. However, recent studies have shown that training involving DT may cause subsequent improvements in gait variables with DT in individuals with PD. The treadmill use was adopted by this study, by promoting greater regularity in step and enhance training. Objective:To investigate immediate effects of gait training associated with cognitive tasks on gait in individuals with PD. Methods: Twenty-two volunteers were randomly divided into two groups: control group (n = 11), who performed gait training on a treadmill for 20 minutes, and the experimental group (n = 11), who performed treadmill gait training for 20 minutes associated with cognitive tasks of verbal fluency, memory, and spatial planning. Participants were evaluated in phase on of antiparkinsonian medication as the demographic, clinical and anthropometric (identification form), cognitive status (Montreal Cognitive Assessment - MoCA), executive function (Frontal Assessment Battery), level of physical disability (Hoehn and Yahr Modified), motor and functional status (Unified Rating Scale for Parkinson`s Disease - UPDRS), and kinematics (Qualisys Motion Capture System). Results: There were not differences between groups, but both showed improvement after the intervention. The control group had an increase in velocity (p = 0.008), stride length (p = 0.04), step length (p = 0.02) and decreased double support time(p = 0.03). The experimental group showed an increase in speed (p = 0.002), stride length (p = 0.008), step length (p = 0.02) and cadence (p = 0.01), as well as a decrease in the width stride (p = 0.001) and total support time (p = 0.02). As the angular variables, the experimental group had a significant increase in the initial contact angle of ankle (p = 0.01). Conclusion: The gait training combined with cognitive activities didn`t provide significant improvements in gait variables with DT, but this study was the first to demonstrate that gait training on treadmill as simple task minimized the negative interference of DT in PD

Design guidelines for developing customised serious games for parkinson's disease rehabilitation using bespoke game sensors

The research presented in this paper proposes a set of design guidelines in the context of a Parkinson's Disease (PD) rehabilitation design framework for the development of serious games for the physical therapy of people with PD. The game design guidelines provided in the paper are informed by the study of the literature review and lessons learned from the pilot testing of serious games designed to suit the requirements of rehabilitation of patients with Parkinson's Disease. The proposed PD rehabilitation design framework employed for the games pilot testing utilises a low-cost, customized and off-the-shelf motion capture system (employing commercial game controllers) developed to cater for the unique requirement of the physical therapy of people with PD. Although design guidelines have been proposed before for the design of serious games in health, this is the first research paper to present guidelines for the design of serious games specifically for PD motor rehabilitation.

Fractional central pattern generators for bipedal locomotion

Locomotion has been a major research issue in the last few years. Many models for the locomotion rhythms of quadrupeds, hexapods, bipeds and other animals have been proposed. This study has also been extended to the control of rhythmic movements of adaptive legged robots. In this paper, we consider a fractional version of a central pattern generator (CPG) model for locomotion in bipeds. A fractional derivative D α f(x), with α non-integer, is a generalization of the concept of an integer derivative, where α=1. The integer CPG model has been proposed by Golubitsky, Stewart, Buono and Collins, and studied later by Pinto and Golubitsky. It is a network of four coupled identical oscillators which has dihedral symmetry. We study parameter regions where periodic solutions, identified with legs’ rhythms in bipeds, occur, for 0<α≤1. We find that the amplitude and the period of the periodic solutions, identified with biped rhythms, increase as α varies from near 0 to values close to unity.

Single Synapse Information Coding in Intraburst Spike Patterns of Central Pattern Generator Motor Neurons

Burst firing is ubiquitous in nervous systems and has been intensively studied in central pattern generators (CPGs). Previous works have described subtle intraburst spike patterns (IBSPs) that, despite being traditionally neglected for their lack of relation to CPG motor function, were shown to be cell-type specific and sensitive to CPG connectivity. Here we address this matter by investigating how a bursting motor neuron expresses information about other neurons in the network. We performed experiments on the crustacean stomatogastric pyloric CPG, both in control conditions and interacting in real-time with computer model neurons. The sensitivity of postsynaptic to presynaptic IBSPs was inferred by computing their average mutual information along each neuron burst. We found that details of input patterns are nonlinearly and inhomogeneously coded through a single synapse into the fine IBSPs structure of the postsynaptic neuron following burst. In this way, motor neurons are able to use different time scales to convey two types of information simultaneously: muscle contraction (related to bursting rhythm) and the behavior of other CPG neurons (at a much shorter timescale by using IBSPs as information carriers). Moreover, the analysis revealed that the coding mechanism described takes part in a previously unsuspected information pathway from a CPG motor neuron to a nerve that projects to sensory brain areas, thus providing evidence of the general physiological role of information coding through IBSPs in the regulation of neuronal firing patterns in remote circuits by the CNS.

Positive effects of auditory cue in locomotor pattern of people with Parkinson's disease (off and on medication)

Gait disorders are identified in people with Parkinson’s disease. The aim of this study was to investigate the effect of auditory cues and medication on kinematic, kinetic and EMG parameters, during different gait phases of people with PD and healthy elderly. Thirty subjects distributed in two groups (Group 1, PD patients off and on medication; Group 2, healthy elderly) participated in this study and were instructed to walk in two experimental conditions: non-cued and cued. Therefore, kinematic, kinetic and electromyography analyses were utilized to investigate the locomotor pattern. Changes in locomotor pattern (greater muscular activity) with auditory cue were observed for PD patients. Regarding the medication, locomotor parameter improvement was observed after levodopa intake in association with the auditory cue. These results confirm the hypothesis about the external cues therapy that could be used as a complement to drug therapy to achieve improvement in the locomotor pattern of PD patients.

Rehabilitation Engineering in Parkinson's disease

Impairment of postural control is a common consequence of Parkinson's disease (PD) that becomes more and more critical with the progression of the disease, in spite of the available medications. Postural instability is one of the most disabling features of PD and induces difficulties with postural transitions, initiation of movements, gait disorders, inability to live independently at home, and is the major cause of falls. Falls are frequent (with over 38% falling each year) and may induce adverse consequences like soft tissue injuries, hip fractures, and immobility due to fear of falling. As the disease progresses, both postural instability and fear of falling worsen, which leads patients with PD to become increasingly immobilized. The main aims of this dissertation are to: 1) detect and assess, in a quantitative way, impairments of postural control in PD subjects, investigate the central mechanisms that control such motor performance, and how these mechanism are affected by levodopa; 2) develop and validate a protocol, using wearable inertial sensors, to measure postural sway and postural transitions prior to step initiation; 3) find quantitative measures sensitive to impairments of postural control in early stages of PD and quantitative biomarkers of disease progression; and 4) test the feasibility and effects of a recently-developed audio-biofeedback system in maintaining balance in subjects with PD. In the first set of studies, we showed how PD reduces functional limits of stability as well as the magnitude and velocity of postural preparation during voluntary, forward and backward leaning while standing. Levodopa improves the limits of stability but not the postural strategies used to achieve the leaning. Further, we found a strong relationship between backward voluntary limits of stability and size of automatic postural response to backward perturbations in control subjects and in PD subjects ON medication. Such relation might suggest that the central nervous system presets postural response parameters based on perceived maximum limits and this presetting is absent in PD patients OFF medication but restored with levodopa replacement. Furthermore, we investigated how the size of preparatory postural adjustments (APAs) prior to step initiation depend on initial stance width. We found that patients with PD did not scale up the size of their APA with stance width as much as control subjects so they had much more difficulty initiating a step from a wide stance than from a narrow stance. This results supports the hypothesis that subjects with PD maintain a narrow stance as a compensation for their inability to sufficiently increase the size of their lateral APA to allow speedy step initiation in wide stance. In the second set of studies, we demonstrated that it is possible to use wearable accelerometers to quantify postural performance during quiet stance and step initiation balance tasks in healthy subjects. We used a model to predict center of pressure displacements associated with accelerations at the upper and lower back and thigh. This approach allows the measurement of balance control without the use of a force platform outside the laboratory environment. We used wearable accelerometers on a population of early, untreated PD patients, and found that postural control in stance and postural preparation prior to a step are impaired early in the disease when the typical balance and gait intiation symptoms are not yet clearly manifested. These novel results suggest that technological measures of postural control can be more sensitive than clinical measures. Furthermore, we assessed spontaneous sway and step initiation longitudinally across 1 year in patients with early, untreated PD. We found that changes in trunk sway, and especially movement smoothness, measured as Jerk, could be used as an objective measure of PD and its progression. In the third set of studies, we studied the feasibility of adapting an existing audio-biofeedback device to improve balance control in patients with PD. Preliminary results showed that PD subjects found the system easy-to-use and helpful, and they were able to correctly follow the audio information when available. Audiobiofeedback improved the properties of trunk sway during quiet stance. Our results have many implications for i) the understanding the central mechanisms that control postural motor performance, and how these mechanisms are affected by levodopa; ii) the design of innovative protocols for measuring and remote monitoring of motor performance in the elderly or subjects with PD; and iii) the development of technologies for improving balance, mobility, and consequently quality of life in patients with balance disorders, such as PD patients with augmented biofeedback paradigms.

Falls in Parkinson's disease : kinematic evidence for impaired head and trunk control

Changes in stride characteristics and gait rhythmicity characterize gait in Parkinson's disease and are widely believed to contribute to falls in this population. However, few studies have examined gait in PD patients who fall. This study reports on the complexities of walking in PD patients who reported falling during a 12-month follow-up. Forty-nine patients clinically diagnosed with idiopathic PD and 34 controls had their gait assessed using three-dimensional motion analysis. Of the PD patients, 32 (65%) reported at least one fall during the follow-up compared with 17 (50%) controls. The results showed that PD patients had increased stride timing variability, reduced arm swing and walked with a more stooped posture than controls. Additionally, PD fallers took shorter strides, walked slower, spent more time in double-support, had poorer gait stability ratios and did not project their center of mass as far forward of their base of support when compared with controls. These stride changes were accompanied by a reduced range of angular motion for the hip and knee joints. Relative to walking velocity, PD fallers had increased mediolateral head motion compared with PD nonfallers and controls. Therefore, head motion could exceed “normal” limits, if patients increased their walking speed to match healthy individuals. This could be a limiting factor for improving gait in PD and emphasizes the importance of clinically assessing gait to facilitate the early identification of PD patients with a higher risk of falling.

Dementia with Lewy bodies and Parkinson's disease

Lewy bodies (LB) in the central nervous system are associated with several different clinical syndromes including Parkinson's disease (PD) and dementia with Lewy bodies (DLB). Long term follow up of PD patients finds up to 78% eventually develop dementia, most of these patients exhibiting fluctuating cognition and visual hallucinations similar to DLB and with extensive cortical LB at autopsy. alpha-Synuclein positive, neuritic pathology, in the putamen of DLB and Parkinson's disease dementia (PDD), may contribute to postural-instability gait difficulty, parkinsonism, diminished levodopa responsiveness and increased neuroleptic sensitivity. Cognitive and neuropsychiatric symptoms improve with cholinesterase inhibitor treatment in both patient groups. DLB and PDD should be seen as different points on a spectrum of LB disease. Distinguishing them as separate disorders may be useful in clinical practice, but may be of limited value in terms of investigating and treating the underlying neurobiology.

Parkinson's disease and gastrointestinal dysfunctions: morphological, neurochemical and functional modifications of the enteric nervous system associated with central dopaminergic impairment

Parkinson’s disease (PD) is frequently associated with gastrointestinal (GI) symptoms, mostly represented by abdominal distension, constipation and defecatory dysfunctions. Despite GI dysfunctions have a major impact on the clinical picture of PD, there is currently a lack of information on the neurochemical, pathological and functional correlates of GI dysmotility associated with PD. Moreover, there is a need of effective and safe pharmacological therapies for managing GI disturbances in PD patients. The present research project has been undertaken to investigate the relationships between PD and related GI dysfunctions by means of investigations in an animal model of PD induced by intranigral injection of 6-hydroxydopamine (6-OHDA). The use of the 6-OHDA experimental model of PD in the present program has allowed to pursue the following goals: 1) to examine the impact of central dopaminergic denervation on colonic excitatory cholinergic and tachykininergic neuromotility by means of molecular, histomorphologic and functional approaches; 2) to elucidate the role of gut inflammation in the onset and progression of colonic dysmotility associated with PD, characterizing the degree of inflammation and oxidative damage in colonic tissues, as well as identifying the immune cells involved in the production of pro-inflammatory cytokines in the gut; 3) to evaluate the impact of chronic treatment with L-DOPA plus benserazide on colonic neuromuscular activity both in control and PD animals. The results suggest that central nigrostriatal dopaminergic denervation is associated with an impaired excitatory cholinergic neurotransmission and an enhanced tachykininergic control, resulting in a dysregulated smooth muscle motor activity, which likely contributes to the concomitant decrease in colonic transit rate. These motor alterations might result from the occurrence of a condition of gut inflammation associated with central intranigral denervation. The treatment with L-DOPA/BE following central dopaminergic neurodegeneration can restore colonic motility, likely through a normalization of the cholinergic enteric neurotransmission, and it can also improve the colonic inflammation associated with central dopaminergic denervation.

Zebrafish as a model of Parkinson's disease

Parkinson’s disease (PD) is the second most common neurodegenerative disease among the elderly. Its etiology is unknown and no disease-modifying drugs are available. Thus, more information concerning its pathogenesis is needed. Among other genes, mutated PTEN-induced kinase 1 (PINK1) has been linked to early-onset and sporadic PD, but its mode of action is poorly understood. Most animal models of PD are based on the use of the neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). MPTP is metabolized to MPP+ by monoamine oxidase B (MAO B) and causes cell death of dopaminergic neurons in the substantia nigra in mammals. Zebrafish has been a widely used model organism in developmental biology, but is now emerging as a model for human diseases due to its ideal combination of properties. Zebrafish are inexpensive and easy to maintain, develop rapidly, breed in large quantities producing transparent embryos, and are readily manipulated by various methods, particularly genetic ones. In addition, zebrafish are vertebrate animals and results derived from zebrafish may be more applicable to mammals than results from invertebrate genetic models such as Drosophila melanogaster and Caenorhabditis elegans. However, the similarity cannot be taken for granted. The aim of this study was to establish and test a PD model using larval zebrafish. The developing monoaminergic neuronal systems of larval zebrafish were investigated. We identified and classified 17 catecholaminergic and 9 serotonergic neuron populations in the zebrafish brain. A 3-dimensional atlas was created to facilitate future research. Only one gene encoding MAO was found in the zebrafish genome. Zebrafish MAO showed MAO A-type substrate specificity, but non-A-non-B inhibitor specificity. Distribution of MAO in larval and adult zebrafish brains was both diffuse and distinctly cellular. Inhibition of MAO during larval development led to markedly elevated 5-hydroxytryptamine (serotonin, 5-HT) levels, which decreased the locomotion of the fish. MPTP exposure caused a transient loss of cells in specific aminergic cell populations and decreased locomotion. MPTP-induced changes could be rescued by the MAO B inhibitor deprenyl, suggesting a role for MAO in MPTP toxicity. MPP+ affected only one catecholaminergic cell population; thus, the action of MPP+ was more selective than that of MPTP. The zebrafish PINK1 gene was cloned in zebrafish, and morpholino oligonucleotides were used to suppress its expression in larval zebrafish. The functional domains and expression pattern of zebrafish PINK1 resembled those of other vertebrates, suggesting that zebrafish is a feasible model for studying PINK1. Translation inhibition resulted in cell loss of the same catecholaminergic cell populations as MPTP and MPP+. Inactivation of PINK1 sensitized larval zebrafish to subefficacious doses of MPTP, causing a decrease in locomotion and cell loss in one dopaminergic cell population. Zebrafish appears to be a feasible model for studying PD, since its aminergic systems, mode of action of MPTP, and functions of PINK1 resemble those of mammalians. However, the functions of zebrafish MAO differ from the two forms of MAO found in mammals. Future studies using zebrafish PD models should utilize the advantages specific to zebrafish, such as the ability to execute large-scale genetic or drug screens.

SPECT-aided diagnostics and genetic risk factors in Parkinson's disease

Hypokinesia, rigidity, tremor, and postural instability are the cardinal symptoms of Parkinson s disease (PD). Since these symptoms are not specific to PD the diagnosis may be uncertain in early PD. Etiology and pathogenesis of PD remain unclear. There is no neuroprotective therapy. Genetic findings are expected to reveal metabolic routes in PD pathogenesis and thereby eventually lead to therapeutic innovations. In this thesis, we first aimed to study the usefulness and accuracy of 123I-b-CIT SPECT in the diagnosis of PD in a consecutive clinic-based material including various movement disorders. We subsequently a genetic project to identify genetic risk factors for sporadic PD using a candidate gene approach in a case-control setting including 147 sporadic PD patients and 137 spouse controls. Dopamine transporter imaging by 123I-b-CIT SPECT could distinguish PD from essential tremor, drug-induced parkinsonism, dystonia and psychogenic parkinsonism. However, b-CIT uptake in Parkinson plus syndromes (PSP and multiple system atrophy) and dementia with Lewy bodies was not significantly different from PD. 123I-b-CIT SPECT could not reliably differentiate PD from vascular parkinsonism. 123I-b-CIT SPECT was 100% sensitive and specific in the diagnosis of PD in patients younger than 55 years but less specific in older patients, due to differential distribution of the above conditions in the younger and older age groups. 123I-b-CIT SPECT correlated with symptoms and detected bilateral nigrostriatal defect in patients whose PD was still in unilateral stage. Thus, in addition to as a differential diagnostic aid, 123I-b-CIT SPECT may be used to detect PD early, even pre-symptomatically in at-risk individuals. 123I-b-CIT SPECT was used to aid in the collection of patients to the genetic studies. In the genetic part of this thesis we found an association between PD and a polymorphic CAG-repeat in POLG1 gene encoding the catalytic subunit of mitochondrial polymerase gamma. The CAG-repeat encodes a polyglutamine tract (polyQ), the two most common lengths of which are 10Q (86-90%) and 11Q. In our Finnish material, the rarer non-10Q or non-11Q length variants (6Q-9Q, 12Q-14Q, 4R+9Q) were more frequent in patients than in spouse controls (10% vs. 3.5 %, p=0.003), or population controls (p=0.001). Therefore, we performed a replication study in 652 North American PD patients and 292 controls. Non-10/11Q alleles were more common in the US PD patients compared to the controls but the difference did not reach statistical significance (p=0.07). This larger data suggested our original definition of variant length allele might need reconsideration. Most previous studies on phenotypic effects of POLG1 polyQ have defined 10Q as the only normal allele. Non-10Q alleles were significantly more common in patients compared to the controls (17.3% vs. 12.3 %, p= 0.005). This association between non-10Q length variants and PD remained significant when compared to a larger set of 1541 literature controls (p=0.00005). In conclusion, POLG1 polyQ alleles other than 10Q may predispose to PD. We did not find association between PD and parkin or DJ-1, genes underlying autosomal recessive parkinsonism. The functional Val158Met polymorphism, which affects the catalytic effect of COMT enzyme, and another coding polymorphism in COMT were not associated with PD in our patient material. The APOE e2/3/4 polymorphism modifies risk for Alzheimer s disease and prognosis of for example brain trauma. APOE promoter and enhancer polymorphisms 219G/T and +113G/C, and APOE e3 haplotypes, have also been shown to modify the risk of Alzheimer s disease but not reported in PD. No association was found between PD and APOE e2/3/4 polymorphism, the promoter or enhancer polymorphisms, or the e3 haplotypes.

Impaired conflict monitoring in Parkinson's disease patients during an oculomotor redirect task

Fallibility is inherent in human cognition and so a system that will monitor performance is indispensable. While behavioral evidence for such a system derives from the finding that subjects slow down after trials that are likely to produce errors, the neural and behavioral characterization that enables such control is incomplete. Here, we report a specific role for dopamine/basal ganglia in response conflict by accessing deficits in performance monitoring in patients with Parkinson's disease. To characterize such a deficit, we used a modification of the oculomotor countermanding task to show that slowing down of responses that generate robust response conflict, and not post-error per se, is deficient in Parkinson's disease patients. Poor performance adjustment could be either due to impaired ability to slow RT subsequent to conflicts or due to impaired response conflict recognition. If the latter hypothesis was true, then PD subjects should show evidence of impaired error detection/correction, which was found to be the case. These results make a strong case for impaired performance monitoring in Parkinson's patients.

Interaction between the 5-HT system and the basal ganglia: functional implication and therapeutic perspective in Parkinson's disease

The neurotransmitter serotonin (5-HT) has a multifaceted function in the modulation of information processing through the activation of multiple receptor families, including G-protein-coupled receptor subtypes (5-HT1, 5-HT2, 5-HT4-7) and ligand-gated ion channels (5-HT3). The largest population of serotonergic neurons is located in the midbrain, specifically in the raphe nuclei. Although the medial and dorsal raphe nucleus (DRN) share common projecting areas, in the basal ganglia (BG) nuclei serotonergic innervations come mainly from the DRN. The BG are a highly organized network of subcortical nuclei composed of the striatum (caudate and putamen), subthalamic nucleus (STN), internal and external globus pallidus (or entopeduncular nucleus in rodents, GPi/EP and GPe) and substantia nigra (pars compacta, SNc, and pars reticulata, SNr). The BG are part of the cortico-BG-thalamic circuits, which play a role in many functions like motor control, emotion, and cognition and are critically involved in diseases such as Parkinson's disease (PD). This review provides an overview of serotonergic modulation of the BG at the functional level and a discussion of how this interaction may be relevant to treating PD and the motor complications induced by chronic treatment with L-DOPA.