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Biomedical subjects

B R Bloem

Publications and source records attributed to B R Bloem.

At least 19 recordsLinked to original sources

Motor imagery of gait: a quantitative approach.

Motor imagery (MI) is widely used to study cognitive aspects of the neural control of action. Prior studies were mostly centred on hand and arm movements. Recently a few studies have used imagery tasks to explore the neurophysiology of human gait, but it remains unclear how to ascertain whether subjects actually perform imagery of gait as requested. Here we describe a new experimental protocol to quantify imagery of gait, by behaviourally distinguishing it from visual imagery (VI) processes and by showing its temporal correspondence with actual gait. Fourteen young healthy subjects performed two imagery tasks and an actual walking (AW) task. During both imagery tasks subjects were sitting on a chair and faced a computer screen that presented photographs of walking trajectories. During one task (MI), subjects had to imagine walking along the walking trajectory. During the other task (VI), subjects had to imagine seeing a disc moving along the walking trajectory. During the AW task, subjects had to physically walk along the same walking trajectory as presented on the photographs during the imagery tasks. We manipulated movement distance by changing the length of the walking trajectory, and movement difficulty by changing the width of the walking trajectory. Subjects reported onset and offset of both actual and imagined movements with a button press. The time between the two button presses was taken as the imagined or actual movement time (MT). MT increased with increasing path length and decreasing path width in all three tasks. Crucially, the effect of path width on MT was significantly stronger during MI and AW than during VI. The results demonstrate a high temporal correspondence between imagined and AW, suggesting that MI taps into similar cerebral resources as those used during actual gait. These results open the possibility of using this protocol for exploring neurophysiological correlates of gait control in humans.

Adult↗

Falls in patients with neuromuscular disorders.

We monitored the incidence and consequences of falls during a 3-month follow-up in 66 patients with a variety of neuromuscular disorders and in 44 age-matched controls. Patients fell more often than controls (27% versus 5%). Falls frequently caused injuries (minor in 79% of subjects and major in 5%) and were often accompanied by fear of falling (58%) and reduced activities (48%). We conclude that falling is a clinically important problem in patients with neuromuscular disorders.

Accidental Falls↗

Diagnostic value of asymmetric striatal D2 receptor upregulation in Parkinson's disease: an [123I]IBZM and [123I]FP-CIT SPECT study.

INTRODUCTION: Striatal postsynaptic D2 receptors in Parkinson's disease (PD) are thought to be upregulated in the first years of the disease, especially contralateral to the clinically most affected side. The aim of this study was to evaluate whether the highest striatal D2 binding is found contralateral to the most affected side in PD, and whether this upregulation can be used as a diagnostic tool. METHODS: Cross-sectional survey was undertaken of 81 patients with clinically asymmetric PD, without antiparkinsonian drugs and with a disease duration of < or = 5 years and 26 age-matched controls. Striatal D2 binding was assessed with [123I]IBZM SPECT, and severity of the presynaptic dopaminergic lesion with [123I]FP-CIT SPECT. RESULTS: The mean striato-occipital ratio of [123I]IBZM binding was significantly higher in PD patients (1.56 +/-0.09) than in controls (1.53 +/-0.06). In PD patients, higher values were found contralateral to the clinically most affected side (1.57 +/-0.09 vs 1.55 +/-0.10 ipsilaterally), suggesting D2 receptor upregulation, and the reverse was seen using [123I]FP-CIT SPECT. However, on an individual basis only 56% of PD patients showed this upregulation. CONCLUSION: Our study confirms asymmetric D2 receptor upregulation in PD. However, the sensitivity of contralateral higher striatal [123I]IBZM binding is only 56%. Therefore, the presence of contralateral higher striatal IBZM binding has insufficient diagnostic accuracy for PD, and PD cannot be excluded in patients with parkinsonism and no contralateral upregulation of D2 receptors, assessed with [123I]IBZM SPECT.

Benzamides↗

Effectiveness of physiotherapy in Parkinson's disease: the feasibility of a randomised controlled trial.

To study the feasibility of a large randomised controlled trial (RCT) evaluating the effectiveness of physiotherapy in Parkinson's disease (PD), 173 patients were asked to participate in a study with random allocation to best practice physiotherapy, or to no physiotherapy. The primary outcome measures were the Parkinson's disease questionnaire-39, the Parkinson activity scale, and a patient preference outcome scale (PPOS). Only 14% of the patients could be included in the study. The PPOS showed the largest effect size (0.74) with a significant group effect (p<0.05). Specific alterations to the study design to ensure successful RCTs in this field are recommended.

Aged↗

CSF analysis differentiates multiple-system atrophy from idiopathic late-onset cerebellar ataxia.

BACKGROUND: Differentiating idiopathic late-onset cerebellar ataxia (ILOCA) from ataxia due to the cerebellar subtype of multiple-system atrophy (MSA-C) can be difficult in the early stages of the disease METHODS: The authors analyzed the levels of various CSF biomarkers in 27 patients with MSA-C and 18 patients with ILOCA and obtained cut-off points for each potential biomarker to differentiate MSA-C from ILOCA. RESULTS: Increased levels of neurofilament light chain (NFL) and neurofilament heavy chain (NFHp35) and decreased levels of the neurotransmitter metabolites homovanillic acid (HVA), 5-hydroxyindoleaceticacid (5-HIAA), and 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG) were observed in MSA-C compared with ILOCA patients. Receiver operating characteristic analysis showed high sensitivity and specificity levels for NFL, NFHp35, and MHPG analysis. At a cut-off of 24.4 ng/L for the NFL analysis, a sensitivity of 79% and a specificity of 94% were obtained for differentiating MSA-C from ILOCA. At a cut-off point for NFHp35 of 129.5 ng/L, sensitivity was 87% and specificity 83%. Analysis of MHPG levels (cut-off 42.5 nM) resulted in a sensitivity of 86% with a specificity of 75%. A multivariate logistic regression model selected NFL, MHPG, and tau as independent predictive biomarkers that separated the MSA-C and ILOCA groups. CONCLUSIONS: Increased levels of neurofilament light chain and tau and decreased levels of 3-methoxy-4-hydroxyphenylethyleneglycol were associated with high accuracy levels in differentiating the cerebellar subtype of multiple-system atrophy from idiopathic late-onset cerebellar ataxia (LOCA). CSF analysis may thus serve as a useful tool in early diagnostic differentiation of LOCA.

Age of Onset↗

Ten steps to identify atypical parkinsonism.

BACKGROUND: Balance impairment is a frequently encountered problem in patients with Parkinson's disease. A profound balance disorder, however, is an atypical feature. METHODS: Tandem gait performance (10 consecutive tandem steps) was judged in 36 consecutive patients with Parkinson's disease and 49 consecutive patients with atypical parkinsonism. RESULTS: Only 9 (18%) patients with atypical parkinsonism had a fully normal tandem gait (not a single side step) as opposed to 33 (92%) patients with Parkinson's disease. Analysis for the subgroup of patients with a disease duration of <3 years yielded the same diagnostic accuracy. CONCLUSIONS: Tandem gait performance has a good diagnostic ability to differentiate patients with atypical parkinsonism from those with Parkinson's disease, and might be used as an additional "red flag" to assist existing clinical tests in identifying atypical parkinsonism.

Aged↗

Frail elderly patients with dementia go too fast.

The reason why patients with dementia fall more often and sustain more fractures than patients without dementia remains unclear. Therefore, the relationship between dementia and gait velocity as a marker for mobility and falls in a cohort of frail elderly (mean age of 77.3 years) inpatients was assessed. Patients with dementia were expected to walk slower than patients without dementia. A trend was indeed observed: absolute gait velocity of 0.59 m/s in patients with dementia (n = 63) versus 0.65 m/s in patients without dementia (n = 62; p = 0.19). After adjustment for parkinsonism and walking aids, however, patients with dementia walked 0.44 m/s faster than patients without dementia (p = 0.02). Probable explanations are frontal lobe disinhibition and lack of insight, causing patients with dementia to walk relatively too fast in the context of their frailty. Therefore, the high risk of falls in dementia may be partially explained by the loss of control of gait velocity.

Accidental Falls↗

Startle responses in Parkinson patients during human gait.

Falls frequently occur in patients with Parkinson's disease (Bloem et al. 2001). One potential source for such falls during walking might be caused by the reaction to loud noises. In normal subjects startle reactions are well integrated in the locomotor activity (Nieuwenhuijzen et al. 2000), but whether this is also achieved in Parkinson patients is unknown. Therefore, in the present study, the startle response during walking was studied in eight patients with Parkinson's disease and in eight healthy subjects. To examine how startle reactions are incorporated in an ongoing gait pattern of these patients, unexpected auditory stimuli were presented in six phases of the step cycle during walking on a treadmill. For both legs electromyographic activity was recorded from biceps femoris and tibialis anterior. In addition, we measured the stance and swing phases of both legs, along with the knee angles of both legs and the left ankle angle. In all subjects and all muscles, responses were detected. The pattern of the responses, latency, duration, and phase-dependent modulation was similar in both groups. However, the mean response amplitude was larger in patients due to a smaller habituation rate. No correlation was found between the degree of habituation and disease severity. Moreover, a decreased habituation was already observed in mildly affected patients, indicating that habituation of the startle response is a sensitive measure of Parkinson's disease. The results complement the earlier findings of reduced habituation of blink responses in Parkinson's disease. With respect to behavioral changes in healthy subjects we observed that startle stimuli induced a shortening of the step cycle and a decrease in range of motion. In the patient group, less shortening of the subsequent step cycle and no decrease in range of motion of the knee and ankle was seen. It is argued that the observed changes might contribute to the high incidence of falls in patients with Parkinson's disease.

Acoustic Stimulation↗

Hemispheric asymmetry and somatotopy of afferent inhibition in healthy humans.

A conditioning electrical stimulus to a digital nerve can inhibit the motor-evoked potentials (MEPs) in adjacent hand muscles elicited by transcranial magnetic stimulation (TMS) to the contralateral primary motor cortex (M1) when given 25-50 ms before the TMS pulse. This is referred to as short-latency afferent inhibition (SAI). We studied inter-hemispheric differences (Experiment 1) and within-limb somatotopy (Experiment 2) of SAI in healthy right-handers. In Experiment 1, conditioning electrical pulses were applied to the right or left index finger (D2) and MEPs were recorded from relaxed first dorsal interosseus (FDI) and abductor digiti minimi (ADM) muscles ipsilateral to the conditioning stimulus. We found that SAI was more pronounced in right hand muscles. In Experiment 2, electrical stimulation was applied to the right D2 and MEPs were recorded from ipsilateral FDI, extensor digitorum communis (EDC) and biceps brachii (BB) muscles. The amount of SAI did not differ between FDI, EDC and BB muscles. These data demonstrate inter-hemispheric differences in the processing of cutaneous input from the hand, with stronger SAI in the dominant left hemisphere. We also found that SAI occurred not only in hand muscles adjacent to electrical digital stimulation, but also in distant hand and forearm and also proximal arm muscles. This suggests that SAI induced by electrical D2 stimulation is not focal and somatotopically specific, but a more widespread inhibitory phenomenon.

Adult↗

[Diagnosis in cerebrospinal fluid: possible applications in neurological practice].

Examination of the cerebrospinal fluid (CSF) is part of the modern diagnostics of many neurological diseases. When an acute or chronic meningitis or encephalitis is suspected, the distinction between an acute viral and a bacterial intrathecal infection can generally be rapidly made via examination of the CSF. In case of a chronic infection this will determine the direction of further microbiological analysis. When there are clinical indications for subarachnoid haemorrhage but no abnormalities on the CT-scan, it can be either demonstrated or excluded by means of spectrophotometric analysis of blood pigments in the CSF. In case of possible multiple sclerosis (MS) and contraindications for MRI, or if the combination of the clinical symptoms and MRI does not yield a definitive diagnosis, then the demonstration of unique oligoclonal IgG-bands in the CSF is an important parameter in confirming a diagnosis of 'MS'. In practice, metastases to the leptomeninges are often detected by means of (repeated) cytopathological analysis of the CSF, which has a higher sensitivity and specificity than MRI. Examination of the CSF also plays an important role in the diagnosis of (hereditary) metabolic encephalopathies in childhood. In case of watery discharge from the nose or ear following trauma or neurosurgery, it can be determined whether or not this is leaking CSF. Analysis of certain brain-specific proteins in the CSF can contribute to the differential diagnosis of dementia syndromes. The added diagnostic value of examination of the CSF in hypokinetic rigidity syndromes is still unclear. The complications of a spinal puncture often remain limited to post-puncture headache. Contraindications include intracranial space-occupying abnormalities, compression of the spinal cord, haemorrhagic diathesis and abnormalities around the puncture site.

Acute Disease↗

Effect of bilateral subthalamic nucleus stimulation on balance and finger control in Parkinson's disease.

We aimed to quantify the effects of bilateral subthalamic nucleus (STN) stimulation in Parkinson's disease (PD) on stance and gait ("axial"motor control), and related this to effects on finger movements ("appendicular" motor control). Fourteen PD patients and 20 matched controls participated. Subjects completed several balance and gait tasks (standing with eyes open or closed, on a normal or foam surface; retropulsion test; walking with eyes closed; walking up and down stairs; Get Up and Go test). Postural control was quantified using trunk sway measurements (angle and angular velocity) in the roll and pitch directions. Subjects further performed a pinch grip reaction time task, where we measured isometric grip forces, as well as movement and reaction times. Patients were examined with STN stimulators switched on or off (order randomised across patients), always after a supramaximal levodopa dosage. STN stimulation improved postural control, as reflected by a reduced trunk sway tremor during stance, a reduced duration for all gait tasks, an increased trunk pitch velocity while rising from a chair, and improved roll stability. STN stimulation also improved finger control, as reflected by a reduced time to reach maximum grip force, without altering reaction times and maximum force levels. Improvements in finger control timing did not correlate with reduced task durations during gait. We conclude that STN stimulation affords improvement of postural control in PD, over and above optimal drug treatment. STN stimulation also provides a simultaneous effect on distal and axial motor control. Because improvements in distal and axial motor control were not correlated, we assume that these effects are mediated by stimulation of different structures within the STN.

Adult↗

[Epileptic seizures during childbirth in a patient with idiopathic generalised epilepsy].

During her first pregnancy, a 37-year-old woman with idiopathic generalised epilepsy that was adequately controlled with lamotrigine experienced a series of epileptic seizures following an elective caesarean section. The attacks were terminated with diazepam. The following day, she developed EEG-confirmed status epilepticus, for which midazolam was administered intravenously. No further attacks were observed and the patient was later discharged in good condition with a healthy newborn son. She remained on lamotrigine therapy. At the end of her second pregnancy, the patient again experienced tonic-clonic seizures. The dosage of lamotrigine was increased and the patient received clonazepam intravenously, but a new seizure quickly occurred. Following an emergency caesarean section with midazolam treatment, a healthy daughter was born. No further attacks were observed. This case history illustrates the occurrence of adult idiopathic generalised epilepsy and highlights the problems that can arise late in pregnancy and during childbirth.

Adult↗

Trunk sway measurements during stance and gait tasks in Parkinson's disease.

To achieve a unified assessment of postural instability in Parkinson's disease (PD) over a range of clinical stance and gait tasks, which may provide an insight into a tendency to fall, we measured trunk sway in the anterior-posterior and medial-lateral directions in freely moving PD patients and age-matched controls. We also measured task duration as time to complete the task or time to loss of balance. Patients had larger amplitudes of trunk sway velocities for stance tasks (e.g. mean pitch velocity when standing on two-legs eyes closed equalled 19.1 +/- 6.4 for PD patients on medication versus 4.8 +/- 0.3 degrees/s for controls, p = 0.0003) and for an expected (following prior warning) retropulsion test (mean roll angle equalled 4.3 +/- 0.5 degrees for PD patients versus 2.2 +/- 0.6 degrees for controls, p = 0.0003) than controls. Patients were more likely to fall earlier for stance tasks, and took longer to complete gait tasks (e.g. walking 3 m eyes closed, mean time 6.8 +/- 0.6 sees versus 4.9 +/- 0.1 sees, p = 0.0001). These differences between patients and controls were, in most cases, independent of medication. Based on these results we defined a simple test battery of stance and gait tasks that could discriminate between PD patients who had recent falls and controls. These results indicate that trunk sway measures recorded during stance and gait tasks provide useful information on balance deficits leading to falls in PD patients.

Aged↗

Differential progression of proprioceptive and visual information processing deficits in Parkinson's disease.

Indirect evidence suggests that patients with Parkinson's disease (PD) have deficits not only in motor performance, but also in the processing of sensory information. We investigated the role of sensory information processing in PD patients with a broad range of disease severities and in a group of age-matched controls. Subjects were tested in two conditions: pointing to a remembered visual target in complete darkness (DARK) and in the presence of an illuminated frame with a light attached to the index finger (FRAME). Differences in pointing errors in these two conditions reflect the effect of visual feedback on pointing. PD patients showed significantly larger constant and variable errors than controls in the DARK and FRAME condition. The difference of the variable error in the FRAME and DARK condition decreased as a function of the severity of PD. This indicates that any deficits in the processing of proprioceptive information occur already at very mild symptoms of PD, and that deficits in the use of visual feedback develop progressively in later stages of the disease. These results provide a tool for early diagnosis of PD and shed new light on the functional role of the brain structures that are affected in PD.

Adult↗