Effect of external cueing on gait in Huntington's disease.

In Huntington's disease (HD) patients, gait is characterized by a timing disorder with marked intraindividual variability in temporal gait parameters (caused by the presence of both hyperkinetic and hypokinetic features). We sought to determine the influence of use of a metronome on gait parameters in patients simultaneously performing motor or cognitive tasks that required attentional resources. The objective is to evaluate the influence of rhythmic cues on gait interference during self-regulated walking and a dual task paradigm in HD. Fifteen HD patients and 15 paired controls were asked to walk and simultaneously perform another motor task (carrying a tray with four full glasses) or a cognitive task (counting backwards). We evaluated the effect of a metronome (set at 100% and 120% of the subject's self-determined cadence) in three different task conditions (gait alone, gait + motor task, gait + cognitive task). The use of auditory cues during free gait and dual tasks did not improve kinematic parameters in HD patients, in contrast to the situation for control subjects (improvement in gait speed and cadence but not stride length when the metronome was set at 120% in all conditions). HD patients have difficulty in synchronizing their footsteps with a metronome, mainly due to attentional deficits.

Role of attentional resources on gait performance in Huntington's disease.

Patients with Huntington's disease (HD) suffer from cognitive deficits with impaired executive functions, including limited attentional resources. We sought to use a dual-task paradigm to evaluate attentional demands and the ability of patients with HD to concentrate on two tasks simultaneously. We analyzed the interference effects of cognitive and motor tasks on walking in HD and the contribution of clinical symptoms to gait disturbances. Patients and controls were asked to perform either a motor task (carrying a tray with four glasses), a cognitive task (counting backwards), or no task at all while walking at their preferred speed. Kinematic spatial parameters, temporal parameters, and angular parameters related to gait were recorded in 15 patients and 15 controls by means of a videomotion analysis system. Gait instability was assessed using the stride-to-stride variability of the various gait parameters. For patients with HD, performing a concurrent cognitive task resulted in a lower gait speed (compared with free walking), with decreased cadence and stride length. However, this effect was not observed in controls. Performing a motor task did not change any kinematic gait parameters in either HD or control subjects. We found correlations between gait speed in the dual cognitive/walking task on one hand and the motor UHDRS score, cognitive status and executive function on the other. Patients with HD had greater difficulty walking while performing a concurrent cognitive task; the drain on attentional resources deteriorated walking performance.

Oral festination in Parkinson's disease: biomechanical analysis and correlation with festination and freezing of gait.

In Parkinson's disease (PD), festination corresponds to a tendency to speed up when performing repetitive movements. First described in gait (and then in handwriting and speech), festination is one of the most disabling axial symptoms. To establish the phenomenology of oral festination (OF) and the condition's potential links with other axial disorders, we submitted a simple, rhythmic, repetitive, vocal motor task to 40 PD patients and 20 controls. Forty-five percent of the 40 patients presented OF, which was strongly associated with gait festination but not with the severity of freezing of gait (FOG) or dysarthria. With respect to the two pathophysiological hypotheses that have been put forward, a possible link with tremor (as previously suggested in tapping) was not confirmed in this study and so, in view of the significant increase in variability observed, we conclude that OF shares the same pathophysiology as gait disorders.

Role of hypokinesia and bradykinesia in gait disturbances in Huntington's disease: a biomechanical study.

OBJECTIVE: To evaluate specific patterns of locomotion in Huntington's disease (HD) and notably the respective roles of hypokinesia (i. e. a decrease in the amplitude of movement) and bradykinesia (i. e. difficulty in executing a movement, slowness) in gait disturbance. METHODS: Kinematic, spatial (stride length, speed), temporal (cadence, speed, and stride time) and angular gait parameters (joint ankle range) were recorded in 15 early-stage HD patients by means of a video motion analysis system and then compared with 15 controls and 15 Parkinson's disease (PD) patients. Hypokinesia was studied in terms of both spatial (decrease in stride length) and angular gait parameters (decrease in joint ankle range), whereas hyperkinesia was characterized by an increase in joint ankle range. Bradykinesia (defined by a decrease in gait velocity) was also assessed in terms of temporal parameters (cadence, stride time). We studied the influence of clinical symptoms (motor dysfunction, chorea, overall disability and cognitive impairment) and the CAG repeat number on gait abnormalities. RESULTS: we observed a clear decrease in gait speed, a decrease in cadence and an increase in stride time (i. e. bradykinesia) for HD, with significant intra-individual variability. Cadence remained normal in PD. In HD, there was no evidence for a clear decrease in stride length, although the latter is a characteristic feature of hypokinetic gait (such as that observed in PD). Angle analysis revealed the coexistence of hyperkinesia and hypokinesia in HD, which thus participate in gait abnormalities. Gait speed in HD was correlated to the motor part of the UHDRS. CONCLUSION: Gait in HD is mainly characterized by a timing disorder: bradykinesia was present, with severe intra-individual variability in temporal gait parameters.

Effect of age on anticipatory postural adjustments in unilateral arm movement.

Aging is frequently accompanied by a deterioration in postural control. Accordingly, the elderly adopt postural strategies in order to maintain balance. The purpose of this study was to compare anticipatory postural adjustments in (healthy) 10 young and 10 elderly subjects using electromyography (EMG) and biomechanical parameters. While standing on a force platform, subjects performed voluntary, arm-raising movements under five conditions: self-paced at three different velocities, self-paced with load and an externally triggered, both at maximal velocity. The force platform provided information on vertical torque (T(z)) and center of pressure anteroposterior displacements (COP). EMG activity was recorded from the biceps femoris, quadriceps, tibialis anterior and soleus muscles. Voluntary movements were associated with an early COP backward shift and an anticipatory T(z). At low velocity, elderly subjects did not show any impairment in stability. At maximal velocity, T(z) was delayed in all conditions in the elderly group, whereas COP latency was reduced only in the self-paced condition without load. Despite this decrease in anticipation, the movement was performed at the same velocity as in younger subjects. The elderly adopted various muscle strategies in order to perform the same movement with less stability. In the self-paced condition, elderly subjects used a hip strategy, whereas young subjects used an ankle strategy. In the triggered condition, the strategy corresponded to increased activation of certain thigh muscles, rather than a sequence modification. Hence, local muscle strategies were used to counteract the overall delay in postural preparation revealed by biomechanical parameters.

Vertical torque allows recording of anticipatory postural adjustments associated with slow, arm-raising movements.

BACKGROUND: When performed in the upright position, voluntary arm-raising movements perturb balance. The maintenance of equilibrium requires postural adjustments, some of which can be anticipatory. It is usually suggested that the role of anticipatory postural adjustments is to stabilise the whole body centre of mass. During movements performed at low velocity (i.e. with a lower inertial perturbation), anticipatory postural adjustments have not systematically been detected by classical recording methods (mainly electromyography). The aim of this study was to use vertical torque to characterise anticipatory postural adjustments in slow movement and to determine the significance of this biomechanical parameter. METHODS: Twenty healthy subjects performed self-paced, right arm-raising movements at low and high velocities. Movements were recorded by an optoelectronic system enabling the synchronization of video, force plate and electromyographic data. The force platform provided information on vertical torque and centre of foot pressure anteroposterior displacement. Electromyography activity was recorded from the right anterior deltoid and the bilateral biceps femoris, tibialis anterior and soleus muscles. FINDINGS: Rapid, voluntary, unilateral movements were associated with an early centre of pressure backward shift, anticipatory vertical torque and electromyographic activities. In slow movements, only the anticipatory changes in vertical torque were consistently observed, with the same latency as in rapid movement. INTERPRETATION: The existence of vertical torque in slow movement (when stabilisation of the centre of mass is not necessary) shows that this parameter does not serve to minimise the centre of mass displacement but rather contributes to the generation of arm movement.

Effects of subthalamic nucleus stimulation and levodopa treatment on gait abnormalities in Parkinson disease.

BACKGROUND: Stimulation of the subthalamic nucleus is proposed for the treatment of patients presenting with severe Parkinson disease. The effect on gait is not clearly established. OBJECTIVES: To evaluate objectively the influence of bilateral subthalamic nucleus stimulation on gait in Parkinson disease and to compare it with the effects of levodopa treatment. METHODS: Ten patients underwent bilateral subthalamic nucleus stimulation. The preoperative and postoperative (3 months after surgery) clinical gait disturbances, as well as spatial and temporal gait parameters, were analyzed in off and on-drug conditions. The gait analysis was performed using a video motion analysis system (optoelectronic VICON system; Oxford Metrics, Oxford, England). RESULTS: In the off condition, there was an improvement after surgery for the total motor score and the gait subscore. In the on-drug condition, there was an improvement in levodopa-induced dyskinesias and the motor score, whereas the gait subscore was unchanged. For the gait parameters measured by the video motion analysis system system, there was also an improvement in the off condition and to a lesser extent in the on-drug condition. CONCLUSIONS: Our method allowed exact quantification of the benefit of surgery on gait parameters. Compared with the levodopa treatment, the effect of stimulation on gait kinematic parameters seems to be qualitatively similar but quantitatively different with a lower benefit on gait velocity and stride length. Concerning the pathophysiology of gait troubles in Parkinson disease, the deficit in control of stride length would be the fundamental deficit. The study underlines the possible role of the subthalamic nucleus on the stride length regulation.

Influence of pallidal stimulation and levodopa on gait and preparatory postural adjustments in Parkinson's disease.

In order to assess the influence of the bilateral internal globus pallidus (GPi) stimulation on gait and postural instability in Parkinson's disease (PD), we compared gait kinematic parameters and preparatory postural adjustments before and 3 months after stimulation in off- and on-drug conditions for seven patients. Gait kinematic parameters and displacements of centre of pressure (CP) and shoulder computed before a lateral raising task of the leg, were recorded using optoelectric Vicon system. Levodopa (L-dopa) induced a clear benefit for gait velocity (related to an increase of stride length) and also an increase of swing phase duration. GPi stimulation had a limited effect, since the increase of gait velocity was induced by a concomitant increase of stride length and cadence corresponding to a compensatory mechanism. The benefit on swing phase duration was also moderate. Displacements of CP were improved mainly by L-dopa. GPi stimulation and L-dopa had the same beneficial effect on the speed at which the CP was transferred back towards the support side, the ankle velocity, the onset time for ankle displacement, and the decrease of shoulder amplitude towards the support side, which reflects a better postural adjustment phase. This study, based on an objective method, revealed that chronic bilateral GPi stimulation may improve gait and preparatory postural adjustments in severe PD patients with a more limited effect than L-dopa.

[Anticipatory postural adjustments associated with arm flexion: interest of vertical torque]. / Ajustements posturaux anticipés lors de la flexion du membre supérieur: intérêt du moment de torsion.

OBJECTIVE: To find a biomechanical parameter able to characterize postural adjustments in different movement conditions. METHODS: The arm-raising movement performed during the upright human position imposes a vertical torque (Tz) that can be measured by a force plate-form. This torque was studied in ten healthy young subjects with opto electronic system Vicon 370. The subjects stood on a force platform, performed shoulder flexion of their right arm, to grasp a handle in front of them, in five conditions : self-paced at 3 different velocities (slow, medium, maximal), triggered by an auditory signal, loaded (1 kg attached to the wrist), all at maximal velocity. In a sixth condition, the arm was passively displaced by an experimenter. RESULTS: Tz displayed a negative phase (counter-clock wise body rotation) in all conditions. A positive phase occurred prior to the negative one, and preceded movement onset only if the movement was voluntary. In the triggered condition, the positive phase of Tz was delayed (- 60 ms) compared to the self-paced condition at maximal velocity (- 155 ms). However Tz onset latency was modified neither by load nor velocity. Tz amplitude increased with increasing velocity, load and in a reaction time condition. CONCLUSIONS: The vertical torque Tz, especially its positive phase gives useful informations about the latency, duration and intensity of the postural preparation related to a voluntary movement, according to the movement parameters. Tz is therefore able to characterise postural adjustments in all conditions, even with low movement velocity.