Our 15 years of research have generated the first short- and long-term efficacy data for speech treatment (Lee Silverman Voice Treatment; LSVT/LOUD) in Parkinson's disease. We have learned that training the single motor control parameter amplitude (vocal loudness) and recalibration of self-perception of vocal loudness are fundamental elements underlying treatment success. This training requires intensive, high-effort exercise combined with a single, functionally relevant target (loudness) taught across simple to complex speech tasks. We have documented that training vocal loudness results in distributed effects of improved articulation, facial expression, and swallowing. Furthermore, positive effects of LSVT/LOUD have been documented in disorders other than Parkinson's disease (stroke, cerebral palsy). The purpose of this article is to elucidate the potential of a single target in treatment to encourage cross-system improvements across seemingly diverse motor systems and to discuss key elements in mode of delivery of treatment that are consistent with principles of neural plasticity.
We have used the phenomenon that speed increases with movement amplitude as a rehabilitation strategy. We tested the hypothesis that the generalized training of amplitude in the limb motor system may reduce bradykinesia and hypokinesia in the upper and lower limbs in subjects with Parkinson's disease (PD) across disease severity (Stage I, n=6; Stage II, n=7; Stage III, n=5). While studies have separately examined the relationship of amplitude to speed in reaching and gait, the same study has not reported the relationship for both limb systems. Moreover, the rehabilitation intervention, Training BIG, is unique in that it applies well-established treatment concepts from a proven treatment for the speech motor system in PD [Lee Silverman Voice Treatment (LSVT)] to the limb motor system. Subjects (n=18) participated in intense practice (1-h sessions/4x week/4 weeks) of large amplitude movements involving the whole body (i.e., head, arm, trunk, and leg) while focusing on the sensory awareness of "movement bigness." Testing procedures were designed to demonstrate the transfer of generalized amplitude practice to speed improvements during functional "untrained" tasks in "uncued" conditions with blinded testers. After therapy, the subjects significantly increased their speed of reaching and gait for the preferred speed condition. This effect was greater when the severity of the disease was less. The results support further application and efficacy studies of Training BIG. Amplitude-based behavioral intervention in people with PD appears to be a simple target that may be applied in different contexts for multiple tasks and results in improved speed-amplitude scaling relations across the upper and lower limbs.
A fundamental issue in the neuromotor control of arm movements is whether the nervous system can use distinctly different muscle activity patterns to obtain similar kinematic outcomes. Although computer simulations have demonstrated several possible mechanical and torque solutions, there is little empirical evidence that the nervous system actually employs fundamentally different muscle patterns for the same movement, such as activating a muscle one time and not the next, or switching from a flexor to an extensor. Under typical conditions, subjects choose the same muscles for any given movement, which suggests that in order to see the capacity of the nervous system to make a different choice of muscles, the nervous system must be pushed beyond the normal circumstances. The purpose of this study, then, was to examine an atypical condition, reaching of cervical spinal cord injured (SCI) subjects who have a reduced repertoire of available distal arm muscles but otherwise a normal nervous system above the level of lesion. Electromyography and kinematics of the shoulder and elbow were examined in the SCI subjects performing a center-out task and then compared to neurologically normal control subjects. The findings showed that the SCI-injured subjects produced reaches with typical global kinematic features, such as straight finger paths, bell-shaped velocities, and joint excursions similar to control subjects. The SCI subjects, however, activated only the shoulder agonist muscle for all directions, unlike the control pattern that involved a reciprocal pattern at each joint (shoulder, elbow, and wrist). Nonetheless, the SCI subjects could activate their shoulder antagonist muscles, elbow flexors, and wrist extensor (extensor carpi radialis) for isometric tasks, but did not activate them during the reaching movements. These results demonstrate that for reaching movements, the SCI subjects used a strikingly different pattern of intact muscle activities than control subjects. Hence, the findings imply that the nervous system is capable of choosing either the control pattern or the SCI pattern. We would speculate that control subjects do not select the SCI pattern because the different choice of muscles results in kinematic features (reduced fingertip speed, multiple shoulder accelerations) other than the global features that are somehow less advantageous or efficient.
Background. Parkinson disease (PD) is characterized by hypometric movements resulting from loss of dopaminergic neurons in the substantia nigra. PD leads to decreased activation of the supplementary motor area (SMA); the net result of these changes is a poverty of movement. The present study determined the impact of 5 Hz repetitive transcranial magnetic stimulation (rTMS) over the SMA on a fine motor movement, handwriting (writing cursive “l”s), and on cortical excitability, in individuals with PD. Methods. In a cross-over design, ten individuals with PD were randomized to receive either 5 Hz or control stimulation over the SMA. Immediately following brain stimulation right handed writing was assessed. Results. 5 Hz stimulation increased vertical size of handwriting and diminished axial pressure. In addition, 5 Hz rTMS significantly decreased the threshold for excitability in the primary motor cortex. Conclusions. These data suggest that in the short term 5 Hz rTMS benefits functional fine motor task performance, perhaps by altering cortical excitability across a network of brain regions. Further, these data may provide the foundation for a larger investigation of the effects of noninvasive brain stimulation over the SMA in individuals with PD.
The purposes of this study were to determine the current status of physical therapists' preparation to work with handicapped and at-risk infants and their families and to identify needs for infant- and family-focused training materials and curricula. Results of a telephone survey of 73 physical therapy programs and a follow-up mail survey of 14 physical therapy programs with infancy specialization options are presented. Students in entry-level programs and postprofessional master's degree programs with infancy specializations commonly received instruction in infancy-related topics. Many students received minimal or no exposure to family-related content. Family assessment and intervention were identified as the areas of highest priority for development of training materials and curricula. The results of this study provide direction for the design of infant- and family-focused training materials and curricula in physical therapy.
Bradykinesia is one of the primary symptoms of Parkinson disease and leads to significant functional limitations for patients. Single joint movement studies, that have investigated the mechanism of bradykinesia, suggest that several features of muscle activity are disrupted, including modulation of burst amplitude and duration, and the number of bursts. It has been proposed that it is the blending of these different burst deficits that collectively defines bradykinesia. This study adds two new approaches to the study of bradykinesia. First, we examined the features of shoulder muscle activities during multijoint arm movement in bradykinetic and control subjects, such that previously reported single joint hypotheses could be tested for generalized arm movement. Second, we directly manipulated speed while keeping distance constant for a large range of speeds. In this manner, we could compare individual trials of muscle activity between controls and subjects with Parkinson's disease (PD) for movements matched for both speed and movement duration. Our results showed that while a multiple burst pattern of shoulder muscles was a common strategy for all subjects (young, elderly controls and PD), subjects with PD showed several burst abnormalities, including deficits in initial agonist burst amplitude and duration at both fast and slow speeds. Subjects with PD also (1) failed to produce a one-burst pattern at fast speeds and, instead, produced a predominance of multiple burst patterns and (2) showed a relationship between the number of burst deficits and the severity of disease. These results extend the findings of single joint studies to multi-joint and similarly indicate that a combination of burst modulation abnormalities correlate with bradykinesia and disease severity.
A unique feature of trunk muscles is that they can be activated to meet functional requirements for combined behaviors, including those related to posture and breathing. Trunk muscles therefore may have developed mechanisms for dealing with simultaneous inputs for different task requirements. This study was designed to test the hypothesis that a linear addition in trunk muscle activities would occur when an isometric trunk task and a pulsed expiration task was performed simultaneously. Surface electromyograms (EMG) were recorded from four trunk regions (medial and lateral back, upper and lower lateral abdomen) in sitting during the performance of the individual isometric trunk task, the individual pressure task, and the combined task (isometric trunk and pressure task). The direction of static holding for the isometric trunk task was varied between flexion and extension positions. For the pressure task subjects produced two consecutive pressure pulses (2/s) to a target oral pressure. For each muscle recording, a linear prediction was calculated from the mathematical addition of the EMG recorded from the individual trunk and pressure tasks. This linear prediction was compared to the actual muscle activity recorded during the combined task. Typically the EMG from two muscles showed linear addition, such that the relative contribution of muscle activity did not change for the combined task. This suggests that the motor commands for each task reached these motor neuron pools essentially unmodified. The other two muscles showed nonlinear combination of two EMG patterns. That is, qualitatively both EMG patterns, specific to each command, were evident in the measured EMG traces for the combined task, but quantitatively the muscle did not meet all criteria for linear addition. Linear addition may provide a simple mechanism for combining breathing-related behaviors (expiratory efforts) with other trunk behaviors (holding against gravity). This suggests that some muscles can be shared for two different voluntary tasks without changing their contribution to either component task. At the same time, nonlinear combination suggests that some muscles are shared, but their contribution to either component task may be modulated, thus avoiding the construction of a third new and unique plan.
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