Kirn R. Kessler

Long-term treatment of cervical dystonia with botulinum toxin A: efficacy, safety, and antibody frequency

Abstract Data from 616 patients suffering from idiopathic cervical dystonia were analyzed to determine the efficacy and safety of treatment with botulinum neurotoxin type A (BoNT/A). Since the specific purpose of this study was to determine the long-term effects of this treatment, the analysis focused specifically on the patients (n = 303) having received six or more injections. Statistical analysis of a standardized documentation showed sustained significant benefit as measured by a disease severity score independent of the type of cervical dystonia. Furthermore, pronounced individual differences were found in response to this treatment although initial clinical scores and doses of BoNT/A were similar. There was no indication of previously unknown adverse events, the only risk being the development of serum antibodies against the toxin. As in previous studies on short-term effects of BoNT/A treatment, the most frequent adverse event was dysphagia, which occurred on average 9.7 days after injection and lasted on average 3.5 weeks. While secondary nonresponse was seen in approx. 5% of patients, antibody tests revealed neutralizing serum antibodies in only 2%. On the basis of the present data, therapy of cervical dystonia with BoNT/A seems to be safe and yields good stable results even after 5 years of treatment.

Transcallosally mediated inhibition of interneurons within human primary motor cortex

The objective of this study was to investigate interhemispheric transcallosal connections between primary motor cortices noninvasively in awake human subjects. For this purpose, focal transcranial magnetic stimulation was performed on eight healthy, right-handed subjects and one patient with congenital collosal agenesis. Using two magnetic stimulators, we investigated the effect of a conditioning magnetic stimulus applied to the motor cortex of one hemisphere on the duration of the silent period (SP) evoked in the first dorsal interosseus (FDI) muscle by a magnetic test stimulus given over the opposite motor cortex. It is well established that SP reflects activation of inhibitory interneurons within primary motor cortex. In all normal subjects, a conditioning stimulus to one hemisphere produced a significant shortening of SP evoked by the test stimulus when the conditioningtest-interval was 10–20 ms. The effect was also observed when an electrical test stimulus was used. The conditioning coil had to be placed over the hand motor area to obtain the maximal effect. The threshold for eliciting this decrease of SP duration was higher than the threshold for eliciting an early excitatory muscle response in the contralateral FDI. Increasing the intensity of the conditioning stimulus led to linear reduction of SP duration. In the patient with callosal agenesis, no such decreasing effect on SP duration was observed. These results suggest that inhibitory interneurons within primary hand motor cortex receive transcallosal inhibitory input from the opposite motor cortex. We propose that modulation of motor cortical interneurons via transcallosal pathways may provide a gain control for the motor cortical output system and subserve interhemispheric coordination in complex, nonsymmetrical bimanual movements.

Role of the cerebellum in visuomotor coordination I. Delayed eye and arm initiation in patients with mild cerebellar ataxia

The initiation of coupled eye and arm movements was studied in six patients with mild cerebellar dysfunction and in six age-matched control subjects. The experimental paradigm consisted of 40 deg step-tracking elbow movements made under different feedback conditions. During tracking with the eyes only, saccadic latencies in patients were within normal limits. When patients were required to make coordinated eye and arm movements, however, eye movement onset was significantly delayed. In addition, removal of visual information about arm versus target position had a pronounced differential effect on movement latencies. When the target was extinguished for 3 s immediately following a step change in target position, both eye and arm onset times were further prolonged compared to movements made to continuously visible targets. When visual information concerning arm position was removed, onset times were reduced. Eye and arm latencies in control subjects were unaffected by changes in visual feedback. The results of this study clearly demonstrate that, in contrast to earlier reports of normal saccadic latencies associated with cerebellar dysfunction, initiation of both eye and arm movements is prolonged during coordinated visuomotor tracking thus supporting a coordinative role for the cerebellum during oculo-manual tracking tasks.

Sinusoidal forearm tracking with delayed visual feedback I. Dependence of the tracking error on the relative delay

Abstract During forearm tracking of a sinusoidally moving target matching of proprioceptive and visual feedback was altered by introducing different visual delays. In five normal subjects seven target frequencies were tested ranging from 0.3 to 1.5 Hz. For each target frequency nine different delays were used ranging from 0 to 120% of the cycle duration with target frequency and delay being varied randomly. Tracking error revealed a cyclic behaviour with an increase up to delays of about 50% of the target cycle duration and an improvement for delays larger than 50%. Modulation of response frequency was less pronounced compared with tracking error variation but also was dependent on relative phase. The response frequency matched the target frequency at delays of 0 and 100% of cycle duration and was slightly lower than the target frequency with relative delays of about 50%. The introduction of a visual delay during sinusoidal forearm tracking leads to a spatial in addition to the temporal mismatch between proprioception and vision. The temporal and the spatial incompatibility influence the tracking performance differentially.