Stella M. Papa

Internal Globus Pallidus Discharge Is Nearly Suppressed during Levodopa- Induced Dyskinesias

The functional status of the globus pallidus internal segment (GPi) plays a key role in mediating the effects of antiparkinsonian drugs. During long‐term levodopa therapy, patients develop abnormal movements, dyskinesias, the pathophysiological basis of which is poorly understood. We recorded single cells in the GPi of parkinsonian monkeys continuously through the “off” and “on” states, and 10 to 15 minutes later during “on with or without dyskinesias,” depending on two doses of levodopa. The transition from the “off” to the “on” state was characterized by a decrease (most cells), no change, or an increase in firing rate of individual cells. During dyskinesias, firing rates declined profoundly in almost all cells, with decrements as low as 97% in individual cells. These changes occurred only when dyskinesias were present. The difference in GPi activity between “on” and “on with dyskinesias” suggests that normal motor function in Parkinsons disease critically depends on fine tuning of the basal ganglia output. Dyskinesias result from an imbalanced low GPi discharge, a circumstance that may be susceptible to development of new therapeutic approaches.

Blockade of cannabinoid type 1 receptors augments the antiparkinsonian action of levodopa without affecting dyskinesias in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated rhesus monkeys.

Drugs acting at cannabinoid type 1 receptors (CB1) have modulatory effects on glutamate and GABA neurotransmission in basal ganglia; thus, they potentially affect motor behavior in the parkinsonian setting. Preclinical trials with diverse cannabinoid agents have shown varied results, and the precise effects of blocking cannabinoid CB1 receptors remain uncertain. We tested behavioral effects of the selective antagonist 1-[7-(2-chlorophenyl)-8-(4-chlorophenyl)-2-methylpyrazolo[1,5-a]-[1,3,5]triazin-4-yl]-3-ethylaminoazetidine-3-carboxylic acid amide benzenesulfonate (CE) as monotherapy and in combination with l-DOPA in treatment-naive and l-DOPA-primed 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated rhesus monkeys with moderate and severe parkinsonism. Motor disability and l-DOPA-induced dyskinesias were scored with a standardized scale after subcutaneous drug administration, and plasma levels of l-DOPA were determined by high-performance liquid chromatography/electrochemical detection. CE doses ranged from 0.03 to 1 mg/kg, and l-DOPA methyl ester doses were selected as optimal and suboptimal doses (maximal and 50% of maximal responses, respectively). CE had no intrinsic effects on motor behavior regardless of the degree of parkinsonism (moderate or severe groups) or previous drug exposure (“de novo” or after l-DOPA priming). Initial CE administration did not affect development of l-DOPA antiparkinsonian responses. In coadministration trials, CE, in a dose-dependent manner, increased responses to l-DOPA (suboptimal doses). These effects were seen in both moderate and severely parkinsonian monkeys as a 30% increase of, predominantly, response duration with no effects on l-DOPA pharmacokinetics. CE did not modify levodopa-induced dyskinesias. These results suggest that selective cannabinoid CB1 antagonists may enhance the antiparkinsonian action of dopaminomimetics and possibly facilitate the use of lower doses, thereby reducing side effects.

Modulation of levodopa-induced motor response complications by NMDA antagonists in Parkinson's disease.

The complex dopamine-glutamate interactions within the basal ganglia are disrupted by chronic nigrostriatal denervation and standard replacement therapy with levodopa. Acute N-methyl-D-aspartate (NMDA) receptor blockade is able to overcome the changes in dopamine D1- and D2-dependent responses and the progressive shortening in the duration of response induced by long-term exposure to levodopa in 6-hydroxydopamine-lesioned rats. Preliminary results further suggest that NMDA receptor blockade can counteract levodopa-induced dyskinesias in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-lesioned non-human primates and parkinsonian patients without substantially altering the motor benefit derived from levodopa. These results appear to be in accordance with our 2-deoxyglucose studies in 6-hydroxydopamine-lesioned rats showing that NMDA receptor blockade can attenuate many of the changes in synaptic activity induced by levodopa, particularly in the striatopallidal complex. Taken together, our observations suggest that abnormal glutamate transmission or dysregulation of NMDA receptor-mediated mechanisms contribute to levodopa-induced motor response complications. Additional preclinical and clinical experiments need to be completed with well tolerated glutamate antagonists to determine the full potential of glutamate receptor blockade as a long-term strategy against levodopa-related motor response complications in Parkinsons disease.

Striatal Overexpression of ΔFosB Reproduces Chronic Levodopa-Induced Involuntary Movements

Long-term dopamine replacement therapy in Parkinsons disease leads to the development of disabling involuntary movements named dyskinesias that are related to adaptive changes in striatal signaling pathways. The chronic transcription factor ΔFosB, which is overexpressed in striatal neurons after chronic dopaminergic drug exposure, is suspected to mediate these adaptive changes. Here, we sought to demonstrate the ability of ΔFosB to lead directly to the abnormal motor responses associated with chronic dopaminergic therapy. Using rAAV (recombinant adenoassociated virus) viral vectors, high levels of ΔFosB expression were induced in the striatum of dopamine-denervated rats naive of chronic drug administration. Transgenic ΔFosB overexpression reproduced the entire spectrum of altered motor behaviors in response to acute levodopa tests, including different types of abnormal involuntary movements and hypersensitivity of rotational responses that are typically associated with chronic levodopa treatment. JunD, the usual protein partner of ΔFosB binding to AP-1 (activator protein-1) sites of genes, remained unchanged in rats with high ΔFosB expression induced by viral vectors. These findings demonstrate that the increase of striatal ΔFosB in the evolution of chronically treated Parkinsons disease may be a trigger for the development of abnormal responsiveness to dopamine and the emergence of involuntary movements.

Inversion of dopamine responses in striatal medium spiny neurons and involuntary movements.

Dopamine influence in the striatum is essential to motor behavior and may lead to involuntary movements in pathologic conditions. The basic mechanisms lie in differential dopamine responses of medium spiny neurons (MSNs) contributing to striatal output pathways. The relationship between striatal discharge and mobility is thus critical to understanding the actions of dopamine. Using extracellular recordings in severely parkinsonian monkeys, we examined the activity changes of MSNs during different levels of dopamine stimulation. The activity of single MSNs was recorded continuously throughout conditions of parkinsonian disability, its reversal, and the exhibition of involuntary movements after levodopa administration. Parkinsonian disability was associated with robust and widely distributed increases of MSN firing. In the parkinsonian state, dopamine influx produced both increases and decreases in the discharge rate of MSNs. Furthermore, in contrast to the expected net reduction of activity, dopamine-induced recovery of mobility occurred with predominant further increases of neuronal activity. In contrast, involuntary movements were associated with a distinctive inversion of the dopamine responses. The activity increases and decreases associated with the recovery of mobility were subsequently inverted in a number of neurons, and these bidirectional changes created large differences of discharge across MSNs. Thus, a markedly dysregulated state of striatal activity develops after chronic dopamine denervation and, in such a state of MSN activity, dopamine induces altered and disproportionate responses. These findings point to the fundamental role of dopamine-mediated balance of striatal outputs for normal movement.

Physiology of freezing of gait

Freezing of gait (FOG) is a common and debilitating, but largely mysterious, symptom of Parkinson disease. In this review, we will discuss the cerebral substrate of FOG focusing on brain physiology and animal models. Walking is a combination of automatic movement processes, afferent information processing, and intentional adjustments. Thus, normal gait requires a delicate balance between various interacting neuronal systems. To further understand gait control and specifically FOG, we will discuss the basic physiology of gait, animal models of gait disturbance including FOG, alternative etiologies of FOG, and functional magnetic resonance studies investigating FOG. The outcomes of these studies point to a dynamic network of cortical areas such as the supplementary motor area, as well as subcortical areas such as the striatum and the mesencephalic locomotor region including the pedunculopontine nucleus (PPN). Additionally, we will review PPN (area) stimulation as a possible treatment for FOG, and ponder whether PPN stimulation truly is the right step forward. Ann Neurol 2016;80:644–659

Human striatal recordings reveal abnormal discharge of projection neurons in Parkinson's disease.

Significance This study is important because it provides the first account of the electrophysiological activity in the human striatum, and it demonstrates major and distinctive abnormalities of neuronal firing in Parkinson’s disease (PD). Up until now, circuit models of PD were based on striatal changes that were never demonstrated in patients. We compared striatal recordings across patients with PD and other neurological disorders [dystonia and essential tremor (ET)], and correlative findings in nonhuman primates. Therefore, the data provided by the present study significantly contribute to understand the role of striatal mechanisms in basal ganglia circuits and in the pathophysiology of PD. Additionally, the study originally reports altered striatal activity in dystonia and activity compatible with unchanged striatal function in ET. Circuitry models of Parkinson’s disease (PD) are based on striatal dopamine loss and aberrant striatal inputs into the basal ganglia network. However, extrastriatal mechanisms have increasingly been the focus of attention, whereas the status of striatal discharges in the parkinsonian human brain remains conjectural. We now report the activity pattern of striatal projection neurons (SPNs) in patients with PD undergoing deep brain stimulation surgery, compared with patients with essential tremor (ET) and isolated dystonia (ID). The SPN activity in ET was very low (2.1 ± 0.1 Hz) and reminiscent of that found in normal animals. In contrast, SPNs in PD fired at much higher frequency (30.2 ± 1.2 Hz) and with abundant spike bursts. The difference between PD and ET was reproduced between 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated and normal nonhuman primates. The SPN activity was also increased in ID, but to a lower level compared with the hyperactivity observed in PD. These results provide direct evidence that the striatum contributes significantly altered signals to the network in patients with PD.

Dual κ‐agonist/μ‐antagonist opioid receptor modulation reduces levodopa‐induced dyskinesia and corrects dysregulated striatal changes in the nonhuman primate model of Parkinson disease

Effective medical management of levodopa‐induced dyskinesia (LID) remains an unmet need for patients with Parkinson disease (PD). Changes in opioid transmission in the basal ganglia associated with LID suggest a therapeutic opportunity. Here we determined the impact of modulating both mu and kappa opioid receptor signaling using the mixed agonist/antagonist analgesic nalbuphine in reducing LID and its molecular markers in the nonhuman primate model.

Prolongation of levodopa responses by glycineB antagonists in parkinsonian primates.

To examine the antiparkinsonian effects of blocking glycineB receptors, we designed a pilot study testing the potent and selective antagonist, PAMQX, in 1‐methyl‐4‐phenyl‐1,2,3,6‐tetrahydropyridine‐treated primates. PAMQX had no intrinsic effects but markedly potentiated the antiparkinsonian action of levodopa. In a dose‐dependent fashion, coadministration of the glycineB antagonist with levodopa extended the response duration by nearly 60%. It is noteworthy that PAMQX, within a considerable dose range, did not cause ataxia or other side effects. These data indicate that blocking N‐methyl‐D‐aspartate receptors selectively to manipulate dopaminergic‐mediated motor responses may be produced effectively by glycineB antagonists. Ann Neurol 2004

Quantitative autoradiographic study on receptor regulation in the basal ganglia in rat model of levodopa-induced motor complications.

SummaryIn order to study neurotransmitter receptor regulation in the basal ganglia involved in the functional changes underlying levodopa-induced motor complications, quantitative autoradiography was used to observe receptor bindings of dopamine D1 and D2, N-methyl-D-aspartate (NMDA), amino-3-hydroxy-5-methylisoxazole propionic acid (AMPA) and amino butyric acid (GABA) in the basal ganglia of rats that had unilateral nigrostriatal lesions and had been chronically treated with levodopa until motor complications developed. The rats were randomly assigned to three groups: normal, denervated and treatment-complicated groups. The results showed that response duration to levodopa became progressively shorter and abnormal involuntary movement (AIM) score was progressively increased during the course of levodopa treatment. Chronic treatment augmented D1 receptors more than denervation, and reduced D2 receptors that were also increased by dopamine denervation. Striatal NMDA receptors were substantially up-regulated in the treatment-complicated group. Levodopa treatment did not change receptors of nigral AMPA, pallidal GABA, and subthalamic GABA, which remained the same as that in denervation group. However, chronic treatment reversed the increase of nigral GABA receptors caused by the lesion. It was concluded that a shortening of response duration and AIM mimicked levodopa-induced motor complications of Parkinson’s patients. These data suggested that up-regulation of dopamine D1 and NMDA receptors in the striatum leads to an imbalance of stimulation through the striatal output pathways, which is associated with levodopa-induced motor complications.