Motor Overactivity Research Articles

Sensory function in cerebral palsy: an overview and considerations for consequences

Alterations of sensory function are poorly recognizable but adequate sensory information and perception is a precondition for adequate motor function. It is of little surprise that in patients with cerebral palsy, the motor disorder is seen as the predominant lesion. This has led to the definition with motor overactivity and weakness in the forefront. However, sensory dysfunction was recognised already in the middle of the last century. It has been described more consistently in the modern literature and proven by fMRI and tractography studies. The sensory disorder can explain a wide part of the symptoms of cerebral palsy at least to some part. It comprises inappropriate and poorly controlled muscle activity, spasticity, impeded motor learning, developmental retardation, and pain. Treatment hence should focus on conveying the perception of stability and experiencing a wider range of different motions by more varying activities and functions. Early onset of treatment may help to reduce the developmental gap between patients and healthy children. Orthopaedic treatment, conservative and surgical, in the first place corrects biomechanically impeding deformities and provides mechanical stability.

Myofunctional Therapy Using Twin Block Appliance in a Class II Malocclusion Patient with ADHD Author(s)Yufita Fitriani, Mega Moeharyono Puteri, Sindy Cornelia Nelwan, Nur Masyitah Iskandar Putri

A 9-year-old male ADHD patient with class II dentoskeletal malocclusion came to the Pediatric Department of Universitas Airlangga, Surabaya, with a chief complaint of a protrusive look. The patient had a behavior disorder of ADHD (Attention Deficit Hyperactivity Disorder), in which its symptoms may be challenging in dental treatment since it heavily depends on the patient’s obedience and case selection. References and similar studies of myofunctional therapy in Class II Malocclusion Patients with ADHD are still scarce. Most patients with class II malocclusion present with hyperactive perioral muscle and altered tongue position. Hence, myofunctional appliance is a reliable treatment choice. A special rule where the patient was asked to focus on the operator’s instruction for 10 minutes and then a 5-minute break, was applied to this patient to overcome ADHD symptoms as a behavior management strategy. This is in line with a theory stating that children with ADHD are prone to distraction, causing them to have a shorter duration of focus, limited sustained attention span, poor impulse control, and motor overactivity compared to normal children. This strategy gave a positive result in maintaining the cooperation of the patient using the twin block for 6 months which is lead to positive progress in malocclusion correction.

Methadone treatment, bruxism, and temporomandibular disorders among male prisoners.

There is little information on bruxism related to illicit drug use. Prolonged drug use may damage the stomatognathic system via oral motor overactivity. The aim of the present study was to compare the rates of bruxism and temporomandibular disorders (TMDs) between prisoners with and without drug-use disorders, to evaluate the association between methadone treatment and bruxism and to assess the possible relationship between bruxism and pain. The sample included 152 male prisoners, 69 of whom were drug users maintained on methadone. All prisoners were examined by an experienced dentist and completed a questionnaire on their oral habits, with the aim of detecting signs or symptoms of TMD and/or bruxism. Additional data were collected from medical files. The prevalence of sleep bruxism and awake bruxism, but not of TMDs, was significantly higher among drug-user than non-drug user prisoners (52.2% vs. 34.9% for sleep bruxism, 59.7% vs. 30.1% for awake bruxism, and 46.3% vs. 25.6% for TMDs, respectively). Participants with awake bruxism were statistically more sensitive to muscle palpation compared with participants with sleep bruxism [rating scores (mean ± SD): 0.32 ± 0.21 vs. 0.19 ± 0.28, respectively]. An association was found between sleep bruxism and awake bruxism. It seems that there is a direct or an indirect association between methadone maintenance treatment and sleep bruxism or awake bruxism in male prisoners.

The motor learning induces plastic changes in dendritic spines of Purkinje cells from the neocerebellar cortex of the rat.

The presynaptic stimulatory activity of parallel fibers on the dendritic spines of cerebellar Purkinje cells (PC) has a strong influence on the organization of motor learning. Motor learning has been shown to modify the synapses established on PC dendritic spines but the plastic changes of the different spine types, possibly underlying motor learning, have not been studied. Adult male Sprague-Dawley rats were trained daily for 26 days using an acrobatic paradigm (AC), at the end of which dendritic spine density and the proportion of the different types of spines was assessed. The learning curves of AC rats reflected a robust decrease in the latency for resolution and in the errors committed during the first week of training, which subsequently stabilized until the end of training. Dendritic spine density was greater in these AC rats, reflected in a larger proportion of thin, mushroom and stubby spines. Since thin spines are associated with acquiring novel information whilst mushroom spines are associated with long-term information storage, there appears to be a strong relationship between AC motor learning and consolidation. The increase in stubby spines could be related to the regulation of excitatory stimulation underlying motor overactivity.

Chapter 34 - Autonomic dysfunction syndromes after acute brain injury

The central autonomic nervous system (CAN) is a multifaceted, richly connected neural network incorporating the hypothalamus, its descending tracts through the brainstem, the insular cortex and down into the spinal cord. All levels of the CAN are susceptible to injury following traumatic brain injury (TBI), whether from focal or diffuse injury. Focal injuries would be expected to produce localized damage to CAN control centers, whereas the effects of diffuse injuries are presumed to be more diverse and/or widely distributed. As the combination of focal and diffuse injury following TBI can vary widely from one individual to the next, the impact of focal injuries is best understood with reference to the focal ischemic stroke literature. Subarachnoid hemorrhage (SAH), a common complication following TBI, also has predictable effects on autonomic control that can be understood with reference to spontaneous SAH literature. Finally, paroxysmal sympathetic hyperactivity (PSH), a syndrome incorporating episodes of heightened sympathetic drive and motor overactivity following minor stimulation, is discussed as an example of what happens when central inhibitory control of spinal cord autonomics is impaired.

Diffuse Cerebral Atrophy, Central Sinus Venous Thrombosis, Hypoplastic Carpus Callosum, Adhd and Vsd in A Child; Anaesthestic Implications

Attention deficit hyperkinetic disorder (ADHD ) is characterized by inattention, poor impulse control, motor overactivity and restlessness.The clinical features most commonly seen in patients with hypoplastic carpus callosum syndrome are microcephaly, seizures, developmental delay or retardation, hypotonia, spasticity and multiple somatic anomalies including arthrogryposis, eye anomalies, syringomyelia in the spinal cord and facial dysmorphisms. The response to general anaesthesia with sevoflurane in this rare complex combination of disorders and its postoperative outcomes were observed.

Clinical and polysomnographic course of childhood narcolepsy with cataplexy

Our aim was to investigate the natural evolution of cataplexy and polysomnographic features in untreated children with narcolepsy with cataplexy. To this end, clinical, polysomnographic, and cataplexy-video assessments were performed at diagnosis (mean age of 10 ± 3 and disease duration of 1 ± 1 years) and after a median follow-up of 3 years from symptom onset (mean age of 12 ± 4 years) in 21 children with narcolepsy with cataplexy and hypocretin 1 deficiency (tested in 19 subjects). Video assessment was also performed in two control groups matched for age and sex at first evaluation and follow-up and was blindly scored for presence of hypotonic (negative) and active movements. Patients’ data at diagnosis and at follow-up were contrasted, compared with controls, and related with age and disease duration. At diagnosis children with narcolepsy with cataplexy showed an increase of sleep time during the 24 h; at follow-up sleep time and nocturnal sleep latency shortened, in the absence of other polysomnographic or clinical (including body mass index) changes. Hypotonic phenomena and selected facial movements decreased over time and, tested against disease duration and age, appeared as age-dependent. At onset, childhood narcolepsy with cataplexy is characterized by an abrupt increase of total sleep over the 24 h, generalized hypotonia and motor overactivity. With time, the picture of cataplexy evolves into classic presentation (i.e. brief muscle weakness episodes triggered by emotions), whereas total sleep time across the 24 h decreases, returning to more age-appropriate levels.

The Ameliorating Effect of Exogenous Melatonin on Urinary Bladder Function in Hyperosmolar Bladder Overactivity and its Influence on the Autonomic Nervous System Activity

This study was designed to investigate the effects of melatonin on the bladder hyperactivity in hyperosmolar-induced overactive bladder (OAB) rats. Additionally, the influence of melatonin on the autonomic nervous system (ANS) using heart rate variability (HRV) analysis was assessed. 40 rats were divided into four groups: I--control (n = 12), II--rats with hyperosmolar OAB (n = 6), III--rats with melatonin pretreatment and hyperosmolar OAB (n = 6) and IV--control with melatonin pretreatment (n = 6). In group III and IV melatonin in dose of 100 mg/kg was given. HRV measurements in 10 rats, as follow: control (n = 2), control after melatonin treatment (n = 2), rats with hyperosmolar OAB without (n = 3), and after (n = 3) melatonin treatment were conducted. This study demonstrates marked influence of melatonin on urinary bladder activity in hyperosmolar-induced OAB rats. These rats showed significantly reduced the detrusor motor overactivity resulting in the improvement of cystometric parameters after melatonin treatment when compared to the control, as follow: a significant increase of intercontraction interval (70%) and functional bladder capacity (67%), as well as a decrease of the basal pressure, detrusor overactivity index and motility index of 96%, 439% and 40%, respectively. ANS activity analysis revealed sympathetic overactivity in OAB rats, and parasympathetic superiority in melatonin treated OAB rats. Melatonin treatment in rats with hyperosmolar OAB (group III) caused significant increase of nuHF parameter (from 51.00 +/- 25.29 to 76.97 +/- 17.43), as well as a decrease of nuLF parameter (from 49.01 +/- 25.26 to 23.03 +/- 17.43) and LF/HF ratio (from 1.280 +/- 0.980 to 0.350 +/- 0.330). In conclusion, melatonin suppresses hyperosmolar OAB, and modulates ANS activity by inhibition of the sympathetic drive. Therefore, melatonin may become a useful agent for OAB management.

A review of paroxysmal sympathetic hyperactivity after acquired brain injury

Severe excessive autonomic overactivity occurs in a subgroup of people surviving acquired brain injury, the majority of whom show paroxysmal sympathetic and motor overactivity. Delayed recognition of paroxysmal sympathetic hyperactivity (PSH) after brain injury may increase morbidity and long-term disability. Despite its significant clinical impact, the scientific literature on this syndrome is confusing; there is no consensus on nomenclature, etiological information for diagnoses preceding the condition is poorly understood, and the evidence base underpinning our knowledge of the pathophysiology and management strategies is largely anecdotal. This systematic literature review identified 2 separate categories of paroxysmal autonomic overactivity, 1 characterized by relatively pure sympathetic overactivity and another group of disorders with mixed parasympathetic/sympathetic features. The PSH group comprised 349 reported cases, with 79.4% resulting from traumatic brain injury (TBI), 9.7% from hypoxia, and 5.4% from cerebrovascular accident. Although TBI is the dominant causative etiology, there was some suggestion that the true incidence of the condition is highest following cerebral hypoxia. In total, 31 different terms were identified for the condition. Although the most common term in the literature was dysautonomia, the consistency of sympathetic clinical features suggests that a more specific term should be used. The findings of this review suggest that PSH be adopted as a more clinically relevant and appropriate term. The review highlights major problems regarding conceptual definitions, diagnostic criteria, and nomenclature. Consensus on these issues is recommended as an essential basis for further research in the area.

Diagnosing Dysautonomia After Acute Traumatic Brain Injury: Evidence for Overresponsiveness to Afferent Stimuli

Baguley IJ, Nott MT, Slewa-Younan S, Heriseanu RE, Perkes IE. Diagnosing dysautonomia after acute traumatic brain injury: evidence for overresponsiveness to afferent stimuli. Objective To differentiate between traumatic brain injury (TBI) subjects with normal and elevated autonomic activity by quantifying cardiac responsivity to nociceptive stimuli and to determine the utility of heart rate variability (HRV) and event-related heart rate changes in diagnosing dysautonomia. Design Prospective cohort study. Setting Intensive care unit in a tertiary metropolitan trauma center. Participants Adults (N=27) with TBI recruited from 79 consecutive TBI admissions comprising 16 autonomically aroused and 11 control subjects matched by age, sex, and injury severity. Interventions None. Main Outcome Measures Immediate: pattern of autonomic changes indexed by HRV and event-related heart rate after nociceptive stimuli. Six months: length of stay, Glasgow Coma Scale, and Disability Rating Scale. Results Heart rate changes (for both HRV and event-related heart rate) were associated with the diagnostic group and 6-month outcome when evaluated pre- and poststimulus but not when evaluated at rest. When assessed on day 7 postinjury, the comparison of HRV and heart rate parameters suggested an overresponsivity to nociceptive stimuli in dysautonomic subjects. These subjects showed a 2-fold increase in mean heart rate relative to subjects with sympathetic arousal of short duration (16% vs 8%), and a 6-fold increase over nonaroused control subjects. Data suggest that post-TBI sympathetic arousal is a spectrum disorder comprising, at one end, a short-duration syndrome and, at the other end, a dramatic, severe sympathetic and motor overactivity syndrome that continued for many months postinjury and associated with a significantly worse 6-month outcome. These findings suggest that it is not the presence of reactivity per se but rather the failure of processes to control for overreactivity that contributes to dysautonomic storming. Conclusions This study provides empirical evidence that dysautonomic subjects show overresponsiveness to afferent stimuli. Findings from this study suggest an evidence-driven revision of diagnostic criteria and a simple clinical algorithm for the improved identification of cases.

Botulinum toxin should be first-line treatment for poststroke spasticity

Each year, about 100 000 people in the UK suffer their first stroke,1 of which some will die, and many of the survivors will suffer significant impairment.2 Much of the...

Normal interhemispheric inhibition in persistent developmental stuttering

Imaging studies suggest a right hemispheric (pre)motor overactivity in patients with persistent developmental stuttering (PDS). The interhemispheric inhibition (IHI) studied with transcranial magnetic stimulation is an established measure of the interplay between right and left motor areas. We assessed IHI in 15 young male adults with PDS and 15 age-matched fluent-speaking subjects. We additionally studied the ipsilateral silent period (iSP) duration. We found no significant between-group difference for IHI or for iSP duration. We conclude that the interplay between the primary motor cortices is normal in patients with PDS. The abnormal right motor and premotor activity observed in functional imaging studies on PDS are not likely to reflect altered primary motor cortex excitability, but are likely to have a different origin.

Autonomic Complications Following Central Nervous System Injury

Severe sympathetic overactivity occurs in several conditions that are recognized as medical emergencies. Following central nervous system injury, a small proportion of individuals develop severe paroxysmal sympathetic and motor overactivity. These individuals have a high attendant risk of unnecessary secondary morbidity. Following acquired brain injury, the syndrome is known by a number of names including dysautonomia and sympathetic storm. Dysautonomia is currently a diagnosis of exclusion and often goes unrecognized. The evidence base for management is almost entirely anecdotal in nature; there has been little structured or prospective research. In contrast, the evidence base for autonomic dysreflexia following spinal cord injury is much stronger, with level 1 evidence for many treatment interventions. This review presents a current understanding of each condition and suggests simple management protocols. With the marked disparity in the literature for the two conditions, the main focus is on the literature for dysautonomia. The similarity between these two conditions and the other autonomic emergency conditions is discussed.

A tetrachoric factor analysis validation of mixed depression

Background Mixed depression, i.e. a Major Depressive Episode plus co-occurring manic/hypomanic symptoms, has recently become the focus of research. However, its diagnostic validity and bipolar nature are still not firmly supported. A bipolar nature could have significant treatment impacts. Study aim The aim was to psychometrically validate the concept of, and the bipolar nature, of mixed depression, by using (for the first time) tetrachoric factor analysis of its hypomanic symptoms. Methods Consecutive 441 Bipolar II Disorder (BP-II), and 289 Major Depressive Disorder (MDD) outpatients were cross-sectionally assessed for Major Depressive Episode (MDE) and concurrent hypomanic symptoms (as binary variables) when presenting for treatment of depression, by a mood disorder specialist psychiatrist (FB), using the Structured Clinical Interview for DSM-IV (as modified by [Akiskal HS, Benazzi F. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J Clin Psychiatry 2005; 66: 914–921.]) in a private practice. Consecutive 275 remitted BP-II were also assessed for past hypomania. Mixed depression was defined as co-occurrence of MDE and 3 or more, usually subthreshold, hypomanic symptoms. Results In multivariable logistic regression, BP-II independent predictor variables were young onset age, MDE recurrences, mixed depression, and bipolar family history. Factor analysis of past hypomania symptoms found three factors: an “irritable mental overactivity” factor, an “elevated mood” factor, and a “motor overactivity” factor. Factor analysis of intradepression hypomanic symptoms in BP-II, and in MDD, found two similar mental and motor overactivity factors. Multivariate regression of the intradepression hypomanic factors versus bipolar validators, such as bipolar family history and young onset age, found significant associations. Discussion Findings could support the diagnostic validity, and the bipolar nature, of mixed depression, on the basis of the close similarities found between the factor structure of inter-depression hypomania and intra-depression hypomanic symptoms. Impacts on treatment of a bipolar nature of mixed depression may be significant (e.g. more use of mood stabilising agents, less/no use of antidepressants).

Agrypnia Excitata: a generalized overactivity syndrome and a useful concept in the neurophysiopathology of sleep

Objectives: To analyse the clinicophysiological features of delirium tremens (DT), Morvan's fibrillary chorea (MC) and fatal familial insomnia (FFI) as representative of the new concept of Agrypnia Excitata (AE). Methods: DT, MC and FFI were compared for their clinical and polysomnographic features and, for MC and FFI, post-mortem verification. Results: DT, MC and FFI all display profound loss of slow-wave sleep (SWS) and abnormal rapid eye movement (REM) sleep with lack of muscular atonia and enacted dreams. Sleep spindles and K complexes are severely reduced. Motor overactivity is associated with increased sympathergic functions. Neuropathology discloses severe loss of neurons in the thalami and cingular areas in FFI, and leakage of antibodies in the thalamus in MC. Conclusions: Based on the similarities in DT, MC and FFI, we propose the new concept of AE as a clinical condition characterized by loss of SWS and abnormal REM sleep, associated with motor and autonomic sympathergic activation. AE is due to dysfunction of the thalamo-limbic system. Moreover, the preservation of light sleep in the face of severe loss of deep sleep in AE argues that 3 rather than the usually considered two (non REM and REM) independent states of sleep exist.

Botulinum treatment of spasticity: why is it so difficult to show a functional benefit?

Clinical experience seems to indicate that botulinum toxin injections can, in selected patients with upper motor neurone syndrome, reduce spasticity and improve voluntary movement and active function. However, double-blind placebo-controlled trials have had difficulty showing active functional improvement, despite the clear ability of botulinum toxin to reduce spasticity. This prompts a re-analysis of the basic assumption that spasticity impairs voluntary movement and a review of the methodology of the clinical trials. Motor dysfunction is usually caused by weakness and the other "negative" features of upper motor neurone syndrome, rather than muscle overactivity. Recent research has explored the pathophysiological basis of the voluntary movement disorder, in particular the role of the various forms of motor overactivity, which might be amenable to botulinum toxin treatment. The failure of double-blind placebo-controlled clinical trials to show improvement in active function is, to a large extent, a result of their methodology, especially patient selection, injection protocols, and the choice of outcome measures. Clinical trials need to be re-designed and based upon expert experience and a better understanding of the pathophysiology of the motor disorder.

Mania and bipolar disorder: Current concepts on assessment, diagnosis and management

Mania is a common psychiatric syndrome characterized by pathological mood elevation, grandiose thinking and motor overactivity. Although current consensus upholds a true distinction between unipolar depression and bipolar disorders, the distinction between various bipolar sub-categories is still a matter for debate, as is the exact distinction between schizophrenia and mania. Most cases are functional in origin but many organic causes have been identified as well as iatrogenic causes from prescribed medication, particularly in susceptible individuals. The underlying aetiology is still poorly understood, although a number of biochemical abnormalities have recently been identified, and the evidence for a genetic role is strong. Its prevalence is universal, with some differences between gender and ethnicity reported, and it displays marked Axis I and II comorbidity. Treatment, both acute and long term, still relies on various traditional combinations of neuroleptics, benzodiazepines and mood stabilisers, particularly Lithium, which now appears to be less effective than previously thought and a shift towards using other mood stabilisers from the anticonvulsant class is now apparent. The exact role for psychological treatment remains unclear with more research required. Good medical management includes; adequate treatment, physical and laboratory investigations, dedicated follow-up and supervision by hospital psychiatrists and community-based care agencies.

Hyperkinetic disorder: assessment and treatment

Hyperkinetic disorder is the generic ICD-10 (WHO, 1992) term used to describe one of the most common childhood psychiatric disorders. It is a severe form of a syndrome which is referred to in DSM–IV (APA, 1994) and the American literature as attention deficit hyperactivity disorder (ADHD). Hyperactivity or hyperkinesis can be defined as “an enduring disposition to behave in a restless, inattentive, distractible and disorganised fashion” (Taylor, 1994). It is thus more than motor overactivity. Diagnostically there are three main groups of symptomatology: overactivity, inattentiveness and impulsiveness.

Nadolol for Self-Injury, Overactivity, Inattention, and Aggression in a Child with Pervasive Developmental Disorder

An 11 year old diagnosed with pervasive developmental disorder, mental retardation, and pica was treated for symptoms of aggression, irritability, self-injurious behavior, motor overactivity, and inattention in an open prospective sequential medication trial comparing baseline (3 months), propranolol (2.4 mg/kg/day for 4 months), and subsequent nadolol (2.4 mg/kg/day for 5 months). Significant differences were found favoring nadolol over propranolol or baseline on measures of inattention, motor overactivity, and self-injurious behavior. Aggression and irritability were rated most improved by teachers during nadolol treatment. No effects of β-blockers on pica were observed. Results are considered suggestive and preliminary because no placebo controls, blind ratings, or treatment reversal withdrawal design were used. Nadolol may have appeared more effective than propranolol because it is more potent or because treatment duration was longer. Peripheral β-adrenergic blockade may be useful in certain children with autistic disorder, but systematic studies are needed before its routine use in children can be recommended.

Magnetic resonance findings in REM sleep behavior disorder

Rapid eye movement (REM) sleep behavior disorder is characterized by bizarre acts during nocturnal sleep that may lead to physical injuries. Dream content suggests that motor overactivity is an attempted dream enactment and polygraphic studies reveal REM stage without atonia, an alteration of REM sleep generation that facilitates excessive motor activity. In 6 patients with REM sleep behavior disorder. MRI of the brain showed multifocal signal intensity lesions suggestive of lacunar infarcts in periventricular regions (5 patients) and in dorsal pontomesencephalic areas (3 patients). REM sleep behavior disorder may be the result of injury to the midrostral tegmentum nuclei, the tegmentoreticular tracts, or both. This condition is easily controlled with clonazepam.