Self-Feeding Interventions for Adults with Tremors

This research analysis was completed in collaboration with Carol Schramek, OTR/L, who works at a skilled nursing facility (SNF) in Iowa run by ABCM corporations. A systematic review of literature was conducted to explore the research question: What evidence-based interventions have been shown to be effective for reducing tremors, improving occupational performance, and/or increasing client satisfaction during self-feeding in adults with resting and/or action tremors? After initial review of 73 articles based on title, 33 articles met our inclusion criteria and were included in our critical appraisal of our topic (CAT). We found there to be a lack of research specifically on self-feeding interventions for adults with an upper-extremity tremor. Due to this gap in research, inferences on the effectiveness of the non-functional interventions for occupation-based tasks in our critical appraisal for self-feeding were made. After reviewing the 33 articles, 8 intervention categories prevailed that had positive impacts on occupational performance for clients with tremor including: limb temperature, positioning of the upper extremity, electrical stimulation, vibration, orthoses, muscular therapy, behavioral training, and various eating devices. After meeting with our collaborator to discuss options for disseminating our findings from the CAT analysis, it was determined that a digital booklet containing basic information ( description, methods, cost, photos) on each intervention category would be most useful for Schramek and her occupational therapy (OT) practitioner colleagues to use when learning about and selecting interventions to use. The booklet was created and sent via email in a pdf and Microsoft Word document to reference and print at her convenience. The purpose of providing a Microsoft Word version, was to enable editing of the files for client-centered customization. To measure the efficacy and benefits of the booklet for the OT practitioners, pre and post surveys were created to assess the OT practitioners\u27 current usage, knowledge, and familiarity of self-feeding interventions for adults with tremor before and after reading through our booklet. Results from our surveys and collaborator feedback indicated that the booklet provided useful information for practitioners to utilize and increased their knowledge on options for interventions to address self-feeding in adults with tremor. OT practitioners should consider all supports and barriers the client has for self-feeding when determining if an intervention included in this critical appraisal is appropriate for their clients with tremor. More research is needed to determine if these interventions are appropriate for OT practitioners to implement for clients with tremors

Does practice of multi-directional stepping with auditory stimulation improve movement performance in patients with Parkinson\u27s disease

Parkinson’s disease (PD) is a debilitating neurodegenerative disorder causing many physical limitations. Rhythmic auditory stimulation (RAS) influences motor complications not alleviated by medicine and has been used to modify straight line walking in this population. However, motor complications are exacerbated during more complex movements including those involving direction changes. Thus immediate RAS effects on direction switch duration (DSD) and other kinematic measures during a multi-directional step task were investigated in PD patients. Long term RAS application was also explored by evaluating functional gait and balance and kinematic step measures before and after 6 weeks of multi-directional stepping either with (Cue, C group) or without (No cue, NC group) RAS use. Evaluations were also administered 1, 4 and 8 weeks after training termination. Kinematic measures were collected during stepping without, then with RAS for the C group and without RAS for the NC group. Step testing/training was performed at slow, normal and fast speeds in forward, back and side directions. Participants with PD switched step direction during the stepping task faster with RAS use before training. Like straight line walking RAS application influenced the more complex task of direction switching and counteracted the well-known bradykinesia in PD. After training both groups improved their functional gait and balance measures and maintained balance improvements for at least 8 weeks. Only the C group retained gait improvements for at least 8 weeks after training termination. Adding RAS resulted in functional benefits not observed in training without it. Kinematic measures compared before and after step training clarified the underlying contributors to functional performances. Both groups reduced the variability of DSD. The C group participants maintained this alteration longer. DSD reduction also occurred after training and was retained for at least 8 weeks for this group. These outcomes further support the advantages of adding RAS to training regiments for those with PD. The current results indicate that RAS effects are not limited to simple activities like straight line walking. Moreover, RAS can be used for improving and maintaining improvements longer in activities involving various forms of transition which present most difficulties for those with PD

Contribution of the subthalamic nucleus to visually guided locomotion

Les ganglions de la base (GB) jouent un rôle important dans le contrôle locomoteur. Ceci est illustré par les troubles locomoteurs dont souffrent les patients atteints de maladies dégénératives qui affectent les GB, telles que la maladie de Parkinson, caractérisées par de petits pas lents et traînants, ainsi qu’un gel de la marche (freezing of gait). Une structure centrale dans les GB est le noyau sous-thalamique (NST), de par son rôle de structure d’entrée et ses projections vers le globus pallidus. Cependant, la nature de la contribution du NST au contrôle de la locomotion, ainsi que les caractéristiques de son activité cellulaire durant la marche, sont peu connues. Afin de mieux comprendre cette contribution, nous avons examiné les propriétés de l’activité neuronale du NST lors de la locomotion non-obstruée et celle sous guidage visuel. Ainsi, nous avons effectué des enregistrements neuronaux chez un chat intact, entraîné à marcher régulièrement sur un tapis roulant et à franchir des obstacles se déplaçant à la même vitesse. Nous avons enregistré 40 cellules montrant une activité reliée au movement du membre antérieur, dont 30 ont montré une activité phasique au cours de la locomotion non obstruée liée aux différentes phases du cycle de la marche, principalement la phase de balancement. Au cours de la modification volontaire de la marche, un groupe de 37/40 cellules, incluant certaines qui étaient modulées pendant la locomotion non-obstruée, ont changé leur fréquence de décharge par rapport à l’obstacle. Ces changement étaient principalement des augmentations de fréquence, mais parfois des diminutions ou une diminution suivie d’une augmentation. Ces modifications se produisaient soit avant l’enjambement de l’obstacle (step-advanced), soit lors de l’enjambement de l’obstacle (step-related). L’activité des cellules step-advanced était indépendante des membres (limb-independent), tandis que celle des cellules step-related était spécifique aux membres (limb-dependent). Cette étude est la première à examiner les caractéristiques de décharge du NST lors de la marche et montre que cette structure contribue au contrôle de la locomotion non obstruée ainsi que la modification volontaire de la marche, en jouant un rôle dans la planification et l’exécution de cette dernière.The Basal ganglia (BG) plays an important role in locomotor control. This is emphasized by the impaired walking of patients with neurodegenerative disorders that affect the BG such as Parkinson’s disease. One important structure in the BG is the subthalamic nucleus (STN), which acts as an input structure for the BG and projects to its output structures. Although the STN has been shown to display movement-related activity during reaching, the nature of its contribution to the control of locomotion, together with the characteristics of its neural activity during locomotion, is poorly known. In order to better understand this contribution, we examined the properties of the neural activity in the STN during unobstructed and visually guided locomotion. To do so, we recorded single neurons in an intact cat trained to walk steadily on a treadmill and to step over obstacles attached to the treadmill belt and moving at the same speed. We recorded 40 neurons which activity was related to the movement of the forelimb during the task. We found that during unobstructed locomotion, many of these cells (30/40) showed phasic step-by-step modulation of their activity pattern, mostly during the swing phase. Most of these swing-related cells discharged throughout the swing phase with no relationship to changes in the pattern of different muscle groups. During voluntary modifications of gait, 37/40 cells, including both cells that were and were not modulated during unobstructed locomotion, changed their firing rate in relationship to the step over the obstacle. The changes observed were mostly increases of activity, but a few cells showed decreases of activity and some showed a decrease followed by an increase of activity. These changes occurred either before the modified step and were classified as step-advanced activity, or they occurred during the modified step and were classified as step-related activity. Step advanced cells mostly showed limb-independent activity, while step related cells showed limb-specific activity. This is the first detailed account of the contribution of the STN to the control of locomotion and our results indicate that the STN is involved in the control of both unobstructed and visually guided locomotion. The results suggest that during unobstructed locomotion, the STN contributes to the general control of the limb trajectory and to both the planning and execution of voluntary changes of gait

Diagnosis and Treatment of Parkinson's Disease

Parkinson's disease is diagnosed by history and physical examination and there are no laboratory investigations available to aid the diagnosis of Parkinson's disease. Confirmation of diagnosis of Parkinson's disease thus remains a difficulty. This book brings forth an update of most recent developments made in terms of biomarkers and various imaging techniques with potential use for diagnosing Parkinson's disease. A detailed discussion about the differential diagnosis of Parkinson's disease also follows as Parkinson's disease may be difficult to differentiate from other mimicking conditions at times. As Parkinson's disease affects many systems of human body, a multimodality treatment of this condition is necessary to improve the quality of life of patients. This book provides detailed information on the currently available variety of treatments for Parkinson's disease including pharmacotherapy, physical therapy and surgical treatments of Parkinson's disease. Postoperative care of patients of Parkinson's disease has also been discussed in an organized manner in this text. Clinicians dealing with day to day problems caused by Parkinson's disease as well as other healthcare workers can use beneficial treatment outlines provided in this book

Designing a comprehensive system for analysis of handwriting biomechanics in relation to neuromotor control of handwriting

A comprehensive system for investigation of biomechanical and neuromuscular processes involved with producing handwriting and drawing was developed. The system included a pen-like grip measuring device that enabled the variations of finger grip force associated with writing and drawing to be measured while holding the pen in tripod grip. The pen was integrated with a digitiser tablet for recording x,ycoordinates and pressure of the nib and a motion analysis system for recording the limb and hand kinematics. It was observed that for line drawing in the y-direction of the tablet, finger forces were directly related to pen tip movement and finger forces were modulated in a repeatable and predictable fashion, while this was not the case for line drawing in the x-direction. This was evidence for longstanding assumptions. Wrist rotation was required for production of lines in the x-direction without excessive deviation. For writing tasks, it was observed that no two tasks performed by one subject share an identical writing process, not even when the writing results are (nearly) identical. The neuromuscular control apparatus is highly flexible and works in a coordinated fashion that allows production of nearly equal end-results by means of different mechanical and therefore neuromuscular processes. For spiral drawing, tremor that originates from the fingers, hand and arm was quantified with the transducer pen. Limb joint kinematics were displayed in three dimensions with colour coding of coordinate sample numbers. This method can reveal the origin of some forms of limb tremor. Pen grip force patterns during signature writing were found to be characteristic for subjects, which relate to their individual pen-hand interaction, resulting from fine control of distal joints. Variation between trials of the same subject was observed, revealing adaptations of the computational processes during writing. The potential for signature verification by means of finger force recording was explored.A comprehensive system for investigation of biomechanical and neuromuscular processes involved with producing handwriting and drawing was developed. The system included a pen-like grip measuring device that enabled the variations of finger grip force associated with writing and drawing to be measured while holding the pen in tripod grip. The pen was integrated with a digitiser tablet for recording x,ycoordinates and pressure of the nib and a motion analysis system for recording the limb and hand kinematics. It was observed that for line drawing in the y-direction of the tablet, finger forces were directly related to pen tip movement and finger forces were modulated in a repeatable and predictable fashion, while this was not the case for line drawing in the x-direction. This was evidence for longstanding assumptions. Wrist rotation was required for production of lines in the x-direction without excessive deviation. For writing tasks, it was observed that no two tasks performed by one subject share an identical writing process, not even when the writing results are (nearly) identical. The neuromuscular control apparatus is highly flexible and works in a coordinated fashion that allows production of nearly equal end-results by means of different mechanical and therefore neuromuscular processes. For spiral drawing, tremor that originates from the fingers, hand and arm was quantified with the transducer pen. Limb joint kinematics were displayed in three dimensions with colour coding of coordinate sample numbers. This method can reveal the origin of some forms of limb tremor. Pen grip force patterns during signature writing were found to be characteristic for subjects, which relate to their individual pen-hand interaction, resulting from fine control of distal joints. Variation between trials of the same subject was observed, revealing adaptations of the computational processes during writing. The potential for signature verification by means of finger force recording was explored

Sensorimotor Control of 3D Arm Movement and Stability in Post-Stroke Hemiparesis

Deficits of the affected arm in people with post-stroke hemiparesis have been generally associated with decreased strength and increased spasticity. These deficits are varied in proximal (shoulder) and distal (elbow) joints which results in an overall impairment during movement or during stabilization of hand position in space. In this study, reaching of the hemiparetic arm in 3D workspace was characterized by a curved and non-smooth endpoint trajectory and a reduced functional range of motion, compared to the unimpaired arm. Smoother trajectories were observed in the acceleration phase more than the deceleration phase, which was common to both the stroke subjects and the neurologically intact controls. Decreased range of motion of the paretic arm in the proximal joint was associated with shoulder weakness, whereas limited range of motion in the elbow appeared to be due to increased antagonist muscle activation. In a task requiring subjects to stabilize their hand at different positions in space, arm weakness and movement synergy constraints may have contributed to stroke survivors generally decreasing the plane of elevation in order to maintain stable arm postures during movement and then stabilize the hand in space. The degree of decreased plane of elevation was negatively correlated with the Fugl-Meyer score. For a task when fine control movement was required simultaneously with a stable arm posture, stroke subjects demonstrated an inability to grade fine muscle control, resulting in larger range of the plane of elevation movements and larger endpoint error. These findings suggest that shoulder strength training might have important implications to the recovery of movement and ability to stabilize the hemiparetic arm during functional tasks

Inhibition and oscillatory activity in human motor cortex

Using transcranial magnetic stimulation (TMS) important information can be obtained about the function of motor cortical circuitry during performance of voluntary movements by conscious human subjects. In particular, pairs of TMS pulses can probe inhibitory pathways projecting onto corticospinal neurones, which themselves project to motoneurones innervating hand muscles. This allows investigation of inhibitory circuitry involved in the performance of specific motor tasks, such as the precision grip. Previous studies have shown that pronounced synchronous oscillatory activity within the hand motor system is present at both cortical and muscular level when subjects maintain steady grasp of an object in a precision grip. The origin of this synchronous activity is unknown. However modelling studies have suggested that inhibitory pathways are likely to play an important role in the generation of cortical oscillations, and therefore TMS was used in this Thesis to investigate the origin of synchrony present during the precision grip task. In the first study, parameters of the paired-pulse test used to measure intracortical inhibition were examined. It was found that by modifying the intensities of the stimuli, and the interval between the paired-pulses, different phases of inhibition could be measured. This enabled specific use of TMS to investigate inhibitory pathways. Both single and paired-pulse TMS were then delivered to the motor cortex of subjects performing a precision grip task. It was found that low intensity TMS could reset the phase of muscle oscillatory activity, consistent with corticospinal neurones being part of the circuitry that generates the oscillatory rhythm. When, in the paired-pulse test, a low intensity stimulus was followed a few milliseconds later with a larger TMS stimulus, in the paired-pulse test, strong intracortical inhibition could be measured. This suggested that inhibitory interneurones activated by low intensity TMS could play an important role in the rhythm-generating network. An additional study looked at the importance of cutaneous receptor feedback on synchrony, by studying the effects of local anaesthesia of the index finger and thumb. Whereas low intensity TMS was shown to enhance synchronous activity between muscle pairs, suppression of cutaneous feedback from the digits reduced it. Results in this Thesis suggest that inhibitory interneurones within the motor cortex are important in the generation of synchronous activity within the hand motor system. This synchrony is also under the influence of cutaneous afferent input

Sensorimotor integration in dystonia: pathophysiology and possible non-invasive approaches to therapy

Dystonia is a condition characterized by excessive and sustained muscle contractions causing abnormal postures and involuntary movements. The pathophysiology of dystonia includes loss of inhibition and abnormal plasticity in the somatosensory and motor systems; however, their contribution to the phenomenology of dystonia is still uncertain, and the possibility to target these abnormalities in an attempt to devise new treatments has not been thoroughly explored. This thesis describes how abnormal inhibition and plasticity in the somatosensory system of dystonic patients can be manipulated to ameliorate motor symptoms by means of peripheral stimulation. First, we characterized electrophysiological and behavioural markers of inhibition in the primary somatosensory cortex in a group of patients with idiopathic cervical dystonia (CD). Outcome measures included a) somatosensory temporal discrimination threshold (STDT); b) paired-pulse somatosensory evoked potentials (PP-SEP) tested with interstimulus intervals (ISIs) of 5, 20 and 40 ms; c) spatial somatosensory inhibition ratio (SIR) by measuring SEP interaction between simultaneous stimulation of the digital nerves in thumb and index finger; d) high-frequency oscillations (HFO) extracted from SEP obtained with stimulation of digital nerves of the index finger. This first investigation demonstrated that increased STDT in dystonia is related to reduced activity of inhibitory circuits within the primary somatosensory cortex, as reflected by reduced PP-SEP inhibition at ISI of 5 ms and reduced area of the late part of the HFO (l-HFO). In a second set of experiments, we applied high frequency repetitive somatosensory stimulation (HF-RSS), a patterned electric stimulation applied to the skin through surface electrodes, to the index finger in a sample of healthy subjects, with the aim to manipulate excitability and inhibition of the primary somatosensory (S1) and motor (M1) cortices. The former was assessed by the same methods used before (STDT, PP-SEP, HFO), with the addition of two psychophysical tasks designed to assess tactile spatial discrimination (grating orientation and bumps tests). Assessment of physiology of M1 was performed by means of short intracortical inhibition (SICI) assessed with TMS; this was performed with multiple conditioning stimulus (CS) intensities (70%, 80%, 90% of the active motor threshold) and with a insterstimulus interval (ISI) between conditioning and test stimulus of 3 ms. It was found that HF-RSS increased inhibition in S1 tested by PP-SEP and HFO; these changes were correlated with improvement in STDT. HF-RSS also enhanced bumps detection, while there was no change in grating orientation test. Finally, there was an increase in SICI, suggesting widespread changes in cortical sensorimotor interactions. Overall, these findings demonstrated that HF-RSS is able to modify the effectiveness of inhibitory circuitry in S1 and M1. The results obtained so far led us to hypothesize that HF-RSS could restore inhibition in dystonic patients, similar to what observed in healthy subjects. To test this, we applied HF-RSS on the index finger in a sample of patients with CD, and tested its effects with some of the outcome measures used before (STDT, PP-SEP, HFO, SIR, SICI). Unexpectedly, the results were opposite to what was predicted. Patients with CD showed a consistent, paradoxical response: after HF-RSS, they had reduced suppression of PP-SEP, as well as decreased HFO area and SICI, and increased SIR. STDT deteriorated after the stimulation protocol, and correlated with reduced measures of inhibition within S1 (PP-SEP at 5 ms ISI, l-HFO area). It was hypothesized that patients with CD have abnormal homeostatic inhibitory plasticity within the sensorimotor cortex and that this is responsible for their abnormal response to HF-RSS. Interestingly, this alteration in plasticity seems to be specific to idiopathic dystonia: when the same protocol was applied to patients with dystonia caused by lesions in the basal ganglia, the response was similar to healthy controls. This result suggests that reduced somatosensory inhibition and abnormal cortical plasticity are not strictly required for the clinical expression of dystonia, and that the abnormalities reported in idiopathic dystonia are not necessarily linked to basal ganglia damage. We then directed our attention to another form of peripheral electrical stimulation, delivered at low frequency (LF-RSS). Previous literature demonstrated that this pattern of stimulation had effects opposite to HF-RSS on tactile performance in healthy subjects; therefore, given the previous findings of abnormal response to HF-RSS in CD, we hypothesized that an inverse response might occur in these patients following LF-RSS as well. Our hypothesis was confirmed by the observation that LF-RSS, applied to the fingers in patients with CD, induced an increase in inhibition in the primary somatosensory and motor cortices. This was reflected by an improvement of STDT and an increase in PP-SEP suppression, HFO area and SICI. With this in mind, in the final project of the thesis, we tested the effects of HF-RSS and LF-RSS applied directly over two affected muscles in different groups of patients with focal hand dystonia (FHD), in an attempt to modulate involuntary muscle activity and, consequently, to ameliorate motor symptoms. Whereas HF-RSS was delivered synchronously over the two muscles, LF-RSS was given either synchronously or asynchronously. Outcome measures included a) PP-SEP obtained by direct stimulation of affected muscles, with ISIs of 5 and 30 ms; b) quantification of electromyographic (EMG) activity from tested muscles; c) SICI recorded from the affected muscles, with CS intensities ranging from 50% to 100% RMT and with an ISI of 3 ms; d) evaluation of hand function, assessed by the box and blocks test (BBT) and the nine-hole peg test (NHPT); e) SIR by measuring SEP interaction between simultaneous stimulation of the two muscles receiving repetitive stimulation. We confirmed the paradoxical response of dystonic patients to HF-RSS, which was reflected in decreased PP-SEP suppression and SICI and increased SIR. Importantly, this was paralleled by an increase in involuntary EMG activity and worse scores at the BBT and NHPT. This results were opposite when LF-RSS was delivered, either in its synchronous or asynchronous version, the latter being slightly more effective. Thus, LF-RSS was able to increase PP-SEP suppression and SICI, decrease SIR and reduce involuntary EMG activity, with consequent improvement in performance in the BBT and NHPT. Overall, our data provide novel insight into the neural mechanisms underlying loss of inhibition and deranged somatosensory plasticity in idiopathic dystonia and bring preliminary evidence that peripheral electrical stimulation can be used as a treatment in idiopathic focal hand dystonia