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Progressive Bradykinesia and Hypokinesia of Ocular Pursuit in Parkinson’S Disease

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Progressive Bradykinesia and Hypokinesia of Ocular Pursuit in Parkinson’S Disease 746 J Neurol Neurosurg Psychiatry 1999;66:746–753 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.66.6.746 on 1 June 1999. Downloaded from Progressive bradykinesia and hypokinesia of ocular pursuit in Parkinson’s disease G U Lekwuwa, G R Barnes, C J S Collins, P Limousin Abstract sustain repetitive motor action. When they Objectives—Patients with Parkinson’s attempt to open or close the hand rapidly or tap disease characteristically have diYculty the foot on the ground, the movement rapidly in sustaining repetitive motor actions. The decreases in amplitude and slows in speed until purpose of this study was to establish if it ceases.2 This disability is easily appreciated in parkinsonian diYculty with sustaining the progressive micrographia of the handwrit- repetitive limb movements also applies to ing of parkinsonian patients. smooth ocular pursuit and to identify any Research in the past 30 years has established pursuit abnormalities characteristic of that Parkinson’s disease impairs control of eye Parkinson’s disease. movements.3–16 Voluntary saccades, such as self Methods—Ocular pursuit in seven pa- paced, predictive, and remembered saccades tients with moderate to severe bradyki- are hypometric, multistep, of reduced velocity, nesia predominant Parkinson’s disease and of increased duration. Visually guided sac- was compared with seven age matched cades are normal. An oculomotor pathway is controls. Predictive and non-predictive known to form one of the basal ganglia loops.17 pursuit of constant velocity target ramps The role of the basal ganglia in the control of were examined. Subjects pursued inter- saccadic eye movements has been extensively mittently illuminated 400/s ramps sweep- reviewed by Hikosaka.18 The role of the basal ing to the left or right with an exposure ganglia seems to be a selective gating of reflex- duration of 480 ms and average interval of ive or voluntary saccades generated by the 1.728 s between presentations. To examine superior colliculus. No study has as yet defined for any temporal changes in peak eye any ocular smooth pursuit pathway through the velocity, eye displacement or anticipatory basal ganglia. Advanced Parkinson’s disease is smooth pursuit the 124 s duration of each known to be associated with reduced ocular 11 14 record was divided into four epochs (E1, smooth pursuit gain. This has been ex- E2, E3, E4), each lasting 31 s and contain- plained on the grounds that advanced Parkin- ing 18 ramp stimuli. Three test conditions son’s disease aVects other structures outside 3 were examined in each subject: predictive the basal ganglia. Reduced ocular pursuit gain (PRD1), non-predictive (NPD), and pre- is a non-specific finding in many cerebral, dictive (PRD2) in that order. brainstem, and cerebellar disorders. It is not characteristic of Parkinson’s disease or other Results—Both patients and controls initi- http://jnnp.bmj.com/ ated appropriate anticipatory pursuit be- neurodegenerative disorders. In this paper we fore target onset in the PRD1 and PRD2 show that the characteristic temporal decay in conditions that enhanced the response the velocity and amplitude associated with limb compared with the NPD condition. The and other skeletal movements in Parkinson’s distinctive findings in patients with Par- disease also applies to smooth pursuit eye kinson’s disease were a reduction in movements. We also use the pursuit of response magnitude compared with con- intermittently presented constant velocity tar- get motion stimuli (ramps)19 20 to show that MRC Human trols and a progressive decline of response on September 30, 2021 by guest. Protected copyright. with stimulus repetition. The deficits were patients with severe Parkinson’s disease are still Movement and able to generate appropriate anticipatory Balance Unit, Institute explained on the basis of easy fatiguability of Neurology, Queen in Parkinson’s disease. smooth eye movements. The anticipatory and visually guided pursuit eye movements of Square, London Conclusions—Ocular pursuit shows dis- WC1N 3BG, UK bradykinetic parkinsonian patients are com- tinct anticipatory movements in Parkin- G U Lekwuwa pared with those of control subjects. G R Barnes son’s disease but peak velocity and C J S Collins displacement are reduced and progres- P Limousin sively decline with repetition as found Methods with limb movements. SUBJECTS Correspondence to: (J Neurol Neurosurg Psychiatry 1999;66:746–753) Dr GR Barnes, MRC We studied ocular pursuit in seven patients Human Movement and with moderate to severe bradykinesia predomi- Balance Unit, Institute of Keywords: ocular pursuit; Parkinson’s disease; bradyki- Neurology, Queen Square, nesia; hypokinesia; prediction nant Parkinson’s disease (mean age 55.9 years, London WC1N 3BG, UK. range 48–66 years) and seven age matched Telephone 0044 171 837 controls (mean age 53.4 years, range 40–80 3611 ext 3069; fax 0044171 278 9836; email Patients with Parkinson’s disease characteristi- years). All patients had idiopathic Parkinson’s [email protected] cally have diYculty initiating movements (aki- disease without dementia, and were receiving nesia). When movements are initiated, they are treatment at the National Hospital for Neurol- Received 6 May 1998 and in of low velocity (bradykinesia), and reduced ogy and Neurosurgery, Queen Square, London revised form 12 6 November 1998 amplitude (hypokinesia). In addition, pa- (table 1). Motor disability was evaluated using Accepted 22 December 1998 tients with Parkinson’s disease are unable to the motor subscale of the unified Parkinson’s Progressive bradykinesia and hypokinesia of ocular pursuit in Parkinson’s disease 747 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.66.6.746 on 1 June 1999. Downloaded from Table 1 Clinical characteristics of patients with Parkinson’s disease and a linear range of at least ±20°. Recorded data were passed through a low pass analogue Bradykinesia rating Illness filter with a cut oV frequency of 80 Hz. The eye Patient Age (y) Sex (UPDRS) duration (y) Medication movement recorders were mounted on a 1 66 M 4 13 Madopar, apomorphine, pergolide helmet assembly which was attached firmly to 2 53 M 4 6 Sinemet, pergolide, apomorphine, the subject’s head. The head was fixed by pad- 3 60 F 4 17 Sinemet, apomorphine ded clamps that fitted snugly on both sides of 4 48 M 4 9 Sinemet, pergolide 5 48 M 3 15 Madopar, amitriptyline the head. Subjects were instructed to track tar- 6 62 F 3 36 Madopar, pergolide, fluoxetine gets using only eye movements. 7 54 M 3 12 Selegeline, sinemet, pergolide STIMULUS disease rating scale (UPDRS).21 All patients The stimulus consisted of a circle of diameter scored 3–4 (maximum score) on the bradyki- 50 minutes of arc with superimposed cross nesia rating items of the UPDRS. Duration of hairs. It was made to move across the screen in disease ranged between 6 and 36 years with a the horizontal plane by a mirror galvanometer. mean duration of 15.4 years. Patients were The motion of the target, which varied from studied 12 hours after withdrawal of medi- one experiment to the other, was controlled by cation. Informed consent was obtained from a computer generated signal. Target appear- each subject and experiments were approved ance was controlled by an electromechanical by the local ethics committee. shutter. Eye movements were calibrated before each record using a simple sinusoidal target RECORDING METHODS waveform at 0.2 Hz. Data were sampled at 125 The subjects were seated in the centre of a Hz. darkened room in front of a semicircular screen EXPERIMENTAL PROCEDURE: PREDICTIVE/NON- of radius 1.5 m. Horizontal eye movements PREDICTIVE RAMP PURSUIT were recorded using an infrared limbus reflec- In the predictive paradigm, subjects pursued tion technique (Iris 6500 system, Skalar Medi- an intermittently illuminated 40°/s constant cal) with a resolution of 5–10 minutes of arc, velocity target (ramp) sweeping alternately to Patients with Parkinson's disease Controls E1_Pos E1_Pos E4_Pos E4_Pos Tgt_Pos Tgt_Pos ABShutter Shutter /s) /s) ° ° 20 20 10 10 0 0 http://jnnp.bmj.com/ –10 –10 –20 –20 –30 –30 Eye/target displacement in PRD1 ( 0 1 2 3 4 5 6 Eye/target displacement in PRD1 ( 0 1 2 3 4 5 6 E1_Vel E1_Vel E4_Vel E4_Vel on September 30, 2021 by guest. Protected copyright. Tgt_Vel Tgt_Vel 40 40 /s) /s) ° ° 20 20 0 0 –20 –20 Eye/target velocity in PRD1 ( –40 Eye/target velocity in PRD1 ( –40 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Time (s) Time (s) Figure 1 Profiles of mean eye displacement (upper traces) and eye velocity (lower traces) in the PRD1 condition averaged across the seven patients with Parkinson’s disease (A) and seven control subjects (B). Each cycle of average has been plotted twice to facilitate viewing. Right going movements are positive. Shutter signal indicates time of presentation of target. Target velocity pulses indicate ramp velocity and duration of target exposure (480 ms). Responses to first and fourth epochs only are plotted for eye displacement (E1_pos, E4_pos) and velocity (E1_vel, E4_vel). Both groups initiated anticipatory pursuit before onset of target motion (arrows). 748 Lekwuwa, Barnes, Collins, et al J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.66.6.746 on 1 June 1999. Downloaded from Patients with Parkinson's disease Controls E1_Pos E1_Pos E4_Pos E4_Pos Tgt_Pos Tgt_Pos ABShutter Shutter /s) /s) ° ° 20 20 10 10 0 0 –10 –10 –20 –20 –30 –30 Eye/target displacement in NPD ( 0 1 2 3 4 5 6 Eye/target displacement in NPD ( 0 1 2 3 4 5 6 E1_Vel E1_Vel E4_Vel E4_Vel Tgt_Vel Tgt_Vel 40 40 /s) /s) ° ° 20 20 0 0 –20 –20 Eye/target velocity in NPD ( –40 Eye/target velocity in NPD ( –40 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Time (s) Time (s) Figure 2 Profiles of mean eye displacement (upper traces) and eye velocity (lower traces) in the NPD condition averaged across the seven patients with Parkinson’s disease (A) and seven control subjects (B).
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