Marianne Vaugoyeau

Postural disorders in Parkinson’s disease

Posture is often affected in Parkinsons disease. Postural abnormalities belong to the motor axial involvement. Generally, postural dysfunction induces clinical impairment at the latest stages of the disease, except in late-onset idiopathic Parkinsons disease and in atypical parkinsonian syndromes. Posture may be affected in its orientation component (stooped posture, camptocormia, Pisa syndrome) or in its balance component (loss of postural reflexes). Overall, postural impairment is poorly improved by levodopa, which implies that it is unlikely due to the nigrostriatal dopaminergic denervation. Several methods of investigation have been proposed but are generally not available in clinical practice. Medical treatment and deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus pars interna are less efficient on axial than on distal motor signs. The pedonculopontine nucleus seems promising as a new target for DBS in combination with the subthalamic nucleus. Physical therapy is, in most cases, the best way to improve postural dysfunction.

Proprioceptive impairment and postural orientation control in Parkinson's disease.

Impairment of postural control is a common consequence of Parkinsons disease (PD). Increasing evidences demonstrate that the pathophysiology of postural disorders in PD includes deficits in proprioceptive processing and integration. However, the nature of these deficits has not been thoroughly examined. We propose to establish a link between proprioceptive impairments and postural deficits in PD using two different experimental approaches manipulating proprioceptive information. In the first one, the subjects stood on a platform that tilted slowly with oscillatory angular movements in the frontal or sagittal planes. The amplitude and frequency of these movements were kept below the semicircular canal perception threshold. Subjects were asked to maintain vertical body posture with and without vision. The orientations of body segments were analyzed. In the second one, the postural control was tested using the tendon-vibration method, which is known to generate illusory movement sensations and postural reactions. Vibrations were applied to ankle muscles. The subjects whole-body motor responses were analyzed from center of pressure displacements. In the first experiment, the parkinsonian patients (PP) were unable to maintain the vertical trunk orientation without vision. Their performances with vision improved, without fully reaching the level of control subjects (CS). In the second experiment, the postural reactions of the PP were similar to those of the CS at the beginning of the perturbation and increased drastically at the end of the perturbations period as compared to those of CS and could induce fall. These results will bring new concepts to the sensorimotor postural control, to the physiopathology of posture, equilibrium and falls in PD and to the role of basal ganglia pathways in proprioception integration. Nevertheless, in order to assess precisely the role played by sensorimotor integration deficits in postural impairments in PD, further studies establishing the links between clinical features and abnormalities are now required.

Coordination of axial rotation and step execution: deficits in Parkinson's disease

To determine why parkinsonian patients (PP) present some difficulties to initiate locomotion, a diagonal step has been investigated in two tasks in five control subjects (CS) and in ten PP. In the first task, the subjects had to perform one diagonal step without change in their orientation (WR); in the second task, they had to perform one diagonal step with a body rotation in the step direction (RO). The defended hypothesis is that the gait initiation deficits in Parkinson disease are a consequence of their difficulties to coordinate al the component of a complex movement. The analysed parameters were the duration of the postural and movement phases, the step length and velocity, and the amplitude of the horizontal ground reaction forces during each phase. Compared to CS, the PP showed a lengthening of the postural phase, a decrease in the step length and velocity and a reduction of the horizontal forces. The comparisons between the performances obtained in the WR versus those obtained the RO show in CS that the performances remained unchanged, whereas in PP the performances were significantly more altered in the RO. It illustrates the specific deficit occurring in PP while performing complex tasks where coordination between several components has to be achieved simultaneously.

A prospective single-blind study of Gamma Knife thalamotomy for tremor

Objective: To evaluate the safety and efficacy of unilateral Gamma Knife thalamotomy (GKT) for treatment of severe tremor with a prospective blinded assessment. Methods: Fifty patients (mean age: 74.5 years; 32 men) with severe refractory tremor (36 essential, 14 parkinsonian) were treated with unilateral GKT. Targeting of the ventral intermediate nucleus (Vim) was achieved with Leksell Gamma Knife with a single shot through a 4-mm collimator helmet. The prescription dose was 130 Gy. Neurologic and neuropsychological assessments including a single-blinded video assessment of the tremor severity performed by a movement disorders neurologist from another center were performed before and 12 months after treatment. MRI follow-up occurred at 3, 6, and 12 months. Results: The upper limb tremor score improved by 54.2% on the blinded assessment (p < 0.0001). All tremor components (rest, postural, and intention) were improved. Activities of daily living were improved by 72.2%. Cognitive functions remained unchanged. Following GKT, the median delay of improvement was 5.3 months (range 1–12 months). The only side effect was a transient hemiparesis associated with excessive edema around the thalamotomy in one patient. Conclusion: This blinded prospective assessment demonstrates that unilateral GKT is a safe and efficient procedure for severe medically refractory tremor. Side effects were rare and transient in this study. Classification of evidence: This study provides Class IV evidence that for patients with severe refractory tremor, GKT is well tolerated and effective in reducing tremor impairment.

Age-related differences in cognitive and postural dual-task performance.

The present experiment assessed, in children aged 7-11 and in adults, whether postural control is affected by cognitive processes and vice versa. Using a dual-task, the level of difficulty of a Stroop task and bipedal quiet stance varied alternatively. We hypothesised that the interference between cognitive and postural tasks was non-linear during childhood with a so-called turning point around 8. Twenty-seven children 7- to 11-years-old and nine adults participated in the experiments. The postural task was executed in a semi-tandem Romberg position. Two cognitive conditions (congruent and non-congruent Stroop conditions) and two postural situations (with and without perturbed proprioceptive inputs) were presented simultaneously with the instruction to respond as correctly as possible while remaining as stable as possible. Results showed that, in the Vib condition, CoP mean velocity decreased with the increased cognitive complexity only in children aged 7. Moreover, the data showed a non-linear decrease in postural sway during childhood, whatever the level of complexity of the cognitive and/or postural tasks. CoP mean amplitude and mean velocity decreased between 7 and 8, and again between age 11 and adults. This study (1) confirmed that the interference between mental activity and postural control can be attributed mainly to attentional limitations, (2) showed the existence of a turning point around 8 in the development of this capacity, and (3) suggested that the mature level of attentional resources was not reached until age 11. Further research is needed to assess the development of attention implied in a cognitive/postural dual-task, including probably another so-called turning point during the adolescence.

Postural Strategies and Sensory Integration: No Turning Point between Childhood and Adolescence

In this study, we investigated the sensory integration to postural control in children and adolescents from 5 to 15 years of age. We adopted the working hypothesis that considerable body changes occurring during these periods may lead subjects to under-use the information provided by the proprioceptive pathway and over-use other sensory systems such as vision to control their orientation and stabilize their body. It was proposed to determine which maturational differences may exist between the sensory integration used by children and adolescents in order to test the hypothesis that adolescence may constitute a specific phase in the development of postural control. This hypothesis was tested by applying an original protocol of slow oscillations below the detection threshold of the vestibular canal system, which mainly serves to mediate proprioceptive information, to the platform on which the subjects were standing. We highlighted the process of acquiring an accurate sensory and anatomical reference frame for functional movement. We asked children and adolescents to maintain a vertical stance while slow sinusoidal oscillations in the frontal plane were applied to the support at 0.01 Hz (below the detection threshold of the semicircular canal system) and at 0.06 Hz (above the detection threshold of the semicircular canal system) with their eyes either open or closed. This developmental study provided evidence that there are mild differences in the quality of sensory integration relative to postural control in children and adolescents. The results reported here confirmed the predominance of vision and the gradual mastery of somatosensory integration in postural control during a large period of ontogenesis including childhood and adolescence. The youngest as well as the oldest subjects adopted similar qualitative damping and segmental stabilization strategies that gradually improved with age without reaching an adults level. Lastly, sensory reweighting for postural strategies as assessed by very slow support oscillations presents a linear development without any qualitative turning point between childhood and adolescence.

Role of sensory information in the control of postural orientation in Parkinson's disease

Clinical findings and experimental studies both in parkinsonian patients and on animal provide evidence that the control of the axial orientation is markedly impaired in Parkinsons disease (stooped posture, Camptocormia, Pisa syndrome). Nevertheless the postural orientation component in Parkinsons disease has been poorly investigated. One study reports that Parkinsonian patients present a major impairment of the postural orientation component in relation with a proprioceptive impairment. On the basis of these results, the visual dependence observed in Parkinsonian patients is re-defined as an adaptive strategy partly compensating for the impaired proprioception.

Axial rotation in Parkinson's disease

Aims: To investigate the ability of patients with Parkinson’s disease to perform a rotation around the longitudinal axis of the body. Three questions were raised. Is body rotation impaired in Parkinson’s disease? Is there a level of the kinematic chain from the head to the foot at which the impairment is more severe? Is the deficit related to the general slowness of movement in Parkinson’s disease? Methods: Kinematic data were recorded. The temporal organisation of body rotation during gait initiation was analysed in 10 patients with Parkinson’s disease, who were all at an advanced stage of the disease and had all experienced falls and freezing during their daily life, and in five controls. The latency of the onset of the rotation of each segment was measured by taking the onset of the postural phase of step initiation as reference value. Locomotor variables were also analysed. Results: Body rotation was found to be impaired in patients with Parkinson’s disease, as the delay in the onset of the rotation of each segment is greater than that in controls. Moreover, a specific uncoupling in the onset of shoulder and pelvis segment rotation was seen in patients. This impairment of rotation is not related only to the general slowness of movements. Conclusion: Patients with Parkinson’s disease were found to have an impairment of posturo-kinetic coordination and impaired capacity to exert appropriate ground reaction forces to orient the pelvis in space.

Coordination between Posture and Phonation in Vocal Effort Behavior

Background: Postural correlates of vocal effort are rarely described in the literature, while they are extensively dealt with in speech therapy. Objectives: This study aims at determining whether body movement is a side effect of vocal effort or an integral part of communication effort behavior. The answer to this question is mainly based on correlations between posture and phonation. Method: Twenty healthy subjects participated in this study. They had to communicate with a listener under 3 conditions requiring different levels of vocal effort. Results: The vocal parameters increased and confirmed that the subjects had made a vocal effort. The kinematic parameters (amplitude and duration of body movement) increased with vocal effort. Lastly, vocal and kinematic characteristics were significantly correlated. Conclusion: The close correlation of posture with vocal production shows that movement is not a mere consequence of vocal effort. Posture and voice are coordinated in communication behavior, and each body segment plays its specific role in the vocal effort behavior.

Body schema building during childhood and adolescence: A neurosensory approach

In order to perceive and act in its environment, the individuals body and its interactions with the sensory and social environment are represented in the brain. This internal representation of the moving body segments is labeled the body schema. Throughout life, body schema develops based on the sensory information used by the moving body and by its interactions with the environment including other people. Internal representations including body schema and representations of the outside world develop with learning and actions throughout ontogenesis and are constantly updated based on different sensory inputs. The aim of this review is to present some concepts and experimental data about body schema, internal representations and updating process during childhood and adolescence, as obtained using a neurosensory approach. From our developmental studies, it was possible to explore the slow maturation of the sensorimotor representations by examining the anticipatory control. By manipulating proprioceptive and visual information, which are at the heart of the construction of body schema, we wished to highlight notable differences between adolescents and young adults on both a postural and perceptual level, which confirms the late maturation of multisensory integration for central motor control.