Oscar Gershanik

Levodopa in the treatment of Parkinson's disease: Current controversies

Levodopa is the most effective symptomatic agent in the treatment of Parkinsons disease (PD) and the “gold standard” against which new agents must be compared. However, there remain two areas of controversy: (1) whether levodopa is toxic, and (2) whether levodopa directly causes motor complications. Levodopa is toxic to cultured dopamine neurons, and this may be a problem in PD where there is evidence of oxidative stress in the nigra. However, there is little firm evidence to suggest that levodopa is toxic in vivo or in PD. Clinical trials have not clarified this situation. Levodopa is also associated with motor complications. Increasing evidence suggests that they are related, at least in part, to the short half‐life of the drug (and its potential to induce pulsatile stimulation of dopamine receptors) rather than to specific properties of the molecule. Treatment strategies that provide more continuous stimulation of dopamine receptors provide reduced motor complications in MPTP monkeys and PD patients. These studies raise the possibility that more continuous and physiological delivery of levodopa might reduce the risk of motor complications. Clinical trials to test this hypothesis are underway. We review current evidence relating to these areas of controversy.

Motor-language coupling: direct evidence from early Parkinson’s disease and intracranial cortical recordings

Language and action systems are functionally coupled in the brain as demonstrated by converging evidence using Functional magnetic resonance imaging (fMRI), electroencephalography (EEG), transcranial magnetic stimulation (TMS), and lesion studies. In particular, this coupling has been demonstrated using the action-sentence compatibility effect (ACE) in which motor activity and language interact. The ACE task requires participants to listen to sentences that described actions typically performed with an open hand (e.g., clapping), a closed hand (e.g., hammering), or without any hand action (neutral); and to press a large button with either an open hand position or closed hand position immediately upon comprehending each sentence. The ACE is defined as a longer reaction time (RT) in the action-sentence incompatible conditions than in the compatible conditions. Here we investigated direct motor-language coupling in two novel and uniquely informative ways. First, we measured the behavioural ACE in patients with motor impairment (early Parkinsons disease - EPD), and second, in epileptic patients with direct electrocorticography (ECoG) recordings. In experiment 1, EPD participants with preserved general cognitive repertoire, showed a much diminished ACE relative to non-EPD volunteers. Moreover, a correlation between ACE performance and action-verb processing (kissing and dancing test - KDT) was observed. Direct cortical recordings (ECoG) in motor and language areas (experiment 2) demonstrated simultaneous bidirectional effects: motor preparation affected language processing (N400 at left inferior frontal gyrus and middle/superior temporal gyrus), and language processing affected activity in movement-related areas (motor potential at premotor and M1). Our findings show that the ACE paradigm requires ongoing integration of preserved motor and language coupling (abolished in EPD) and engages motor-temporal cortices in a bidirectional way. In addition, both experiments suggest the presence of a motor-language network which is not restricted to somatotopically defined brain areas. These results open new pathways in the fields of motor diseases, theoretical approaches to language understanding, and models of action-perception coupling.

LEVODOPA IN THE TREATMENT OF PARKINSON'S DISEASE : A CONSENSUS MEETING

Levodopa (in combination with a peripheral dopadecarboxylase inhibitor) substantially improves the quality of life of patients. However, physicians are not always comfortable prescribing it, and its administration is often delayed to retard the development of motor complications or is restricted to patients with relatively advanced disease, because there is a fear that the decreased response of parkinsonian symptoms may result from a self-limiting effect of the drug. Moreover, long-term treatment with levodopa is claimed by some to induce the degeneration of dopaminergic neurons, thereby accelerating disease progression. Whether long-term administration of levodopa in patients may result in the irreversible appearance of side effects or accelerate the neurodegenerative process is a crucial question, and it is therefore legitimate to ask whether one should delay the introduction or limit its use in patients. To address these questions, a meeting of experts was held in Paris (January 8–9, 1998) to see whether general agreement could be reached concerning the interpretation of studies of levodopa toxicity in tissue culture, in animal models of parkinsonism, and in patients. Most of the experts agreed that the administration of levodopa was not dangerous for patients. Nevertheless, there are still conflicting results and unanswered questions. This is why this consensus on levodopa treatment of patients with Parkinson’s disease (see below) is followed by additional comments made by some of the experts.

Opposite roles of D1 and D5 dopamine receptors in locomotion revealed by selective antisense oligonucleotides

CONTRALATERAL rotations induced by the D1-like agonist SKF 38393 in unilaterally 6-hydroxydopamine-lesioned rats were completely prevented by the administration of the D1-like antagonist SCH 23390. A similar result was obtained after intracerebroventricular administration of an antisense oligodeoxynucleotide for the D1 receptor (D1R-as). Contrariwise, administration of a D5R-as potentiated the effects of SKF 38393, showing a 60% increase in the rotational scores. Both effects were reversible upon cessation of D1R-as or D5R-as treatment and were also specific since rotational scores in rats treated with vehicle or with a randomly designed oligodeoxynucleotide were not modified. These results suggest that whereas D1 receptors play a facilitatory role in locomotion, D5 receptors exert an inhibitory effect.

Action-verb processing in Parkinson’s disease: new pathways for motor–language coupling

Recent studies suggest that action-verb processing is particularly affected in early stage Parkinson’s disease (PD), highlighting the potential role of subcortical areas in language processing and in the semantic integration of actions. However, this disorder-related language impairment is frequently unrecognized by clinicians and often remains untreated. Early detection of action-language processing deficits could be critical for diagnosing and developing treatment strategies for PD. In this article, we review how action-verb processing is affected in PD and propose a model in which multiple and parallel frontotemporal circuits between the cortex and the basal ganglia provide the anatomic substrate for supporting action-language processing. We hypothesize that contextual coupling of action-language networks are partially dependent on cortical–subcortical integration, and not only on somatotopic motor cortical organization or in a mirror neuron system. This hypothesis is supported by both experimental and clinical evidence. Then, we identify further research steps that would help to determine the reliability of action-language impairments as an early marker of PD. Finally, theoretical implications for clinical assessment and for models of action-language interaction (action–perception cycle theories, mirror system models of language, and embodied cognition approaches to language) are discussed.

Behavioral sensitization to different dopamine agonists in a parkinsonian rodent model of drug-induced dyskinesias

Repeated treatment with dopamine (DA) receptor agonists strongly potentiates contralateral turning behavior due to selective stimulation of D1 or D2-class receptors in 6-hydroxydopamine (6-OHDA)-lesioned rats. This phenomenon, referred to as sensitization, is believed to be related to the motor response complications (dyskinesias, on-off states) that occur during chronic administration of levodopa in Parkinsons disease patients. In recent years a new method for the evaluation of abnormal involuntary movements (AIMs) secondary to dopaminergic stimulation in 6-OHDA-lesioned rats was described. These AIMs resemble dyskinesias as seen in parkinsonian patients under levodopa therapy. Our objective was to evaluate the effects of repeated treatment with different regimes of DA agonists on turning behavior and on an AIMs scale in 6-OHDA lesioned rats, with the aim of discriminating between drugs with different dyskinesia-inducing potential. In addition, we explored the effects of a previous exposure to a DA agonist (priming) on the behavioral response to the subsequent administration of a DA agonist with the same or different pharmacologic profile. Our results show that in apomorphine-treated rats, rotational behavior and AIMs run a parallel course of enhancement, while in those receiving quinpirole there is a dissociation, suggesting that they could be mediated by different mechanisms. The finding of a significant priming effect on subsequent testing of 6-OHDA lesioned rats should be borne in mind as the use of these pharmacological tests in the screening of well lesioned animals could lead to an erroneous interpretation of further results on dyskinesias and rotational behavior.

How embodied is action language? Neurological evidence from motor diseases

Although motor-language coupling is now being extensively studied, its underlying mechanisms are not fully understood. In this sense, a crucial opposition has emerged between the non-representational and the representational views of embodiment. The former posits that action language is grounded on the non-brain motor system directly engaged by musculoskeletal activity - i.e., peripheral involvement of ongoing actions. Conversely, the latter proposes that such grounding is afforded by the brains motor system - i.e., activation of neural areas representing motor action. We addressed this controversy through the action-sentence compatibility effect (ACE) paradigm, which induces a contextual coupling of motor actions and verbal processing. ACEs were measured in three patient groups - early Parkinsons disease (EPD), neuromyelitis optica (NMO), and acute transverse myelitis (ATM) patients - as well as their respective healthy controls. NMO and ATM constitute models of injury to non-brain motor areas and the peripheral motor system, whereas EPD provides a model of brain motor system impairment. In our study, EPD patients exhibited impaired ACE and verbal processing relative to healthy participants, NMO, and ATM patients. These results indicate that the processing of action-related words is mainly subserved by a cortico-subcortical motor network system, thus supporting a brain-based embodied view on action language. More generally, our findings are consistent with contemporary perspectives for which action/verb processing depends on distributed brain networks supporting context-sensitive motor-language coupling.

Different roles of D-1 and D-2 dopamine receptors involved in locomotor activity of supersensitive mice

Simultaneous stimulation of both D-1 and D-2 receptors is necessary to reverse reserpine-induced akinesia in mice. The effect of supersensitivity on locomotor function was studied in mice after treatment with reserpine for five days. The response of these animals to a mixed D-1/D-2 agonist, pergolide, or to a presynaptic dopamine (DA) releaser, amphetamine, was increased 3-fold, indicating behavioural supersensitivity. Under these conditions, both selective D-1 and D-2 dopamine receptor agonist (SKF 38393 and LY 171555, respectively), given separately, induced locomotor activity. The D-1 antagonist, SCH 23390, inhibited the effect of both SKF 38393 and LY 171555, whereas the DA synthesis inhibitor, alpha-methyl-p-tyrosine (AMPT), and the D-2 antagonist, sulpiride, only abolished the effect of LY 171555. Moreover, AMPT increased the response to SKF 38393 by 80%. The amphetamine-mediated responses were abolished by SCH 23390 whereas sulpiride did not block them. Thus, stimulation of the D-1 receptor seems crucial in supersensitive animals. In another set of experiments, AMPT was administered to mice pretreated with reserpine for five days in order to fully deplete DA stores. Low doses of LY 171555 reduced the response of these animals to SKF 38393 by 60% whereas higher doses potentiated it. This bimodal effect of LY 171555 was blocked by sulpiride. Since amphetamine was unable to reverse the reserpine-induced akinesia in these mice, we can conclude that the inhibitory effect of LY 171555 is not related to presynaptic inhibition of DA release.

Assessing the non-motor symptoms of Parkinson's disease: MDS-UPDRS and NMS Scale.

Although Parkinsons disease (PD) is characterized by typical motor manifestations, non‐motor symptoms (NMS) are an outstanding part of the disease. At present, several specific instruments for assessment of NMS are available. The objective of our study was to determine the performance of the Movement Disorder Society‐Unified Parkinsons Disease Rating Scale (MDS‐UPDRS): Part I – Non‐Motor Aspects of Experiences of Daily Living (nM‐EDL) compared with the Non‐Motor Symptoms Scale (NMSS).

Differential gene expression induced by chronic levodopa treatment in the striatum of rats with lesions of the nigrostriatal system

Levodopa, the major treatment for patients with Parkinsons disease, has been shown to induce a variety of compensatory effects, including facilitation of sprouting by dopaminergic neurons, in experimental animals with lesions leading to denervation of the striatum. To better understand the cellular and molecular environment where most of these compensatory changes take place, in particular elements that might contribute to the recovery of dopaminergic innervation, we have constructed a differential expression library enriched in transcripts from the striata of rats with lesions of the medial forebrain bundle treated with levodopa for 6 months. We have used this library to screen an expression array of rat genes representing the major cell functions, and have identified several that are involved in neurotrophic mechanisms and plasticity. We have confirmed the differential expression of selected transcripts by non‐radioactive in situ hybridization, and report that the growth factor pleiotrophin, myelin basic protein and calmodulin are overexpressed in the denervated striatum of levodopa‐treated rats.