Shoulder Shrugging Research Articles

Factors associated with pseudoparalysis in patients with extensive chronic and atraumatic rotator cuff injury

BackgroundPatients with massive chronic atraumatic rotator cuff injuries can be asymptomatic or present severe shoulder dysfunction, a condition known as pseudoparalysis. Our hypothesis is that integrity of the subscapularis, hypertrophy of the Teres minor, and a complete tear of the long head of the biceps tendon are associated with improved active forward flexion range in such patients. Therefore, the objective of this study was to evaluate factors associated with pseudoparalysis. MethodsThis was a single-center cross-sectional study that included patients with massive chronic atraumatic rotator cuff injuries. Range of motion of the affected shoulder, demographic data, specific tests for rotator cuff assessment, and imaging studies were collected. ResultsA total of 68 patients (71 shoulders) were included in the study. At initial evaluation, 41 patients exhibited active forward flexion of the shoulder greater than 90º (No Pseudoparalysis group). Patients with active forward flexion less than 90º (n = 29) underwent subacromial injection of local anesthetic and were then reevaluated. In 15 patients the pseudoparalysis was resolved (False Pseudoparalysis group) and 14 maintained active forward flexion of less than 90° (True Pseudoparalysis group). ConclusionWe concluded that the presence of shoulder shrug sign, Goutallier grade III and IV fatty infiltration and a full-thickness tear of the subscapularis were risk factors for the occurrence of pseudoparalysis. Tear extension, as described by Wieser et al, also demonstrated statistical difference between groups, with greater anterior tear extension (involvement of subscapularis tendon) and greater global tear extension observed in True Pseudoparalysis group. Level of evidenceLevel III; Cross Sectional Design; Epidemiology Study

Enhancing motor imagery in the third-person perspective by manipulating sense of body ownership with virtual reality.

Virtual reality (VR)-guided motor imagery (MI) is a widely used approach for motor rehabilitation, especially for patients with severe motor impairments. Most approaches provide visual guidance from the first-person perspective (1PP). MI training with visual guidance from the third-person perspective (3PP) remains largely unexplored. We argue that 3PP MI training has its own advantages and can supplement 1PP MI. For some movements beyond the view of 1PP, such as shoulder shrugging and other axial movements, MI are suitable performed under 3PP. However, the efficiency of existing paradigms for 3PP MI is unsatisfactory. We speculate that the absence of sense of body ownership (SOO) from 3PP could be one possible factor and hypothesize that 3PP MI could be enhanced by eliciting SOO over a 3PP avatar. Based on our hypothesis, a novel paradigm was proposed to enhance 3PP MI by inducing full-body illusion (FBI) from 3PP, which is similar to the so-called out-of-body experience (OBE), using synchronous visuo-tactile stimulus with VR. The event-related Electroencephalograph (EEG) desynchronization (ERD) at motor-related regions from 31 healthy participants were calculated and compared with a control paradigm without "OBE" FBI induction. This study attempts to enhance 3PP MI with FBI induction. It offers an opportunity to perform MI guided by action observation from 3PP with elicited SOO to the observed avatar. We believe that 3PP MI could provide more possibilities for effective rehabilitation training, when SOO could be elicited to a virtual avatar and the present work demonstrates its viability and effectiveness.

Physiotherapy for Alzheimer’s Disease: A Case Report

Alzheimer's disease is a progressive neurological condition characterized by brain changes resulting in the accumulation of specific proteins, leading to brain shrinkage and eventual cell death. It is the primary cause of dementia, resulting in a gradual decline in memory, cognition, behaviour, and social skills, impairing overall functionality. The case study involves an 84-year-old woman displaying symptoms of Alzheimer's disease requiring physiotherapy rehabilitation. Assessment reveals joint pain, abnormal gait, respiratory issues due to pneumonia, reduced balance and cognitive function, concentration difficulties, impaired decision-making, fluctuating moods, and behavioural issues such as depression and aggression. Physical examination shows shoulder shrugging and slight tension in the upper trapezius muscle. The rehabilitation program involves various interventions like stretching, strengthening, aerobic exercises, breathing exercises, lung clearance techniques, active range of motion exercises, postural control, and gait training. The role of the physiotherapist is to address the both physical and cognitive decline and improve mood and behaviour.

Plum-blossom needle therapy for Tourette syndrome: A case report

IntroductionTourette syndrome (TS) is a neurodevelopmental disorder characterized by the childhood onset of motor and phonic tics, frequently accompanied by behavioral and psychiatric comorbidities. Existing treatments for tics raise safety concerns. In China, acupuncture has been a widely utilized approach for TS, and one specific traditional acupuncture method, plum-blossom needle therapy (PBNT), has exhibited favorable tolerance among pediatric patients. In this report, we present a case of TS treated using PBNT. Case presentationAn 11-year-old boy diagnosed with Tourette syndrome for over five years presented with frequent loud throat clearing, eye blinking, severe abdominal tensing, shoulder shrugging, and upper limb twitching. Plum-blossom needle therapy (PBNT) was administered for 8 weeks, involving two sessions per week. The boy's tic symptoms gradually ameliorated, ultimately becoming minimal following the 8-week treatment period. Specifically, the Yale Global Tic Severity Scale (YGTSS) score decreased from 71 to 20, and the TS Clinical Global Impression Scale of Improvement (CGI-I) score reached 1, signifying 'very much improved' post-treatment. However, the Children and Adolescents' Quality of Life Scale (CAQOL) score exhibited minimal variation, moving from 146 to 150. ConclusionThis case suggests that plum-blossom needle therapy (PBNT) is well-tolerated by children and may be effective in alleviating tics associated with Tourette syndrome (TS). However, further research, particularly large-sample randomized controlled trials, is imperative to establish the efficacy and effectiveness of PBNT.

A Novel Action Transformer Network for Hybrid Multimodal Sign Language Recognition

Sign language fills the communication gap for people with hearing and speaking ailments. It includes both visual modalities, manual gestures consisting of movements of hands, and non-manual gestures incorporating body movements including head, facial expressions, eyes, shoulder shrugging, etc. Previously both gestures have been detected; identifying separately may have better accuracy, but much communicational information is lost. A proper sign language mechanism is needed to detect manual and non-manual gestures to convey the appropriate detailed message to others. Our novel proposed system contributes as Sign Language Action Transformer Network (SLATN), localizing hand, body, and facial gestures in video sequences. Here we are expending a Transformer-style structural design as a “base network” to extract features from a spatiotemporal domain. The model impulsively learns to track individual persons and their action context in multiple frames. Furthermore, a “head network” emphasizes hand movement and facial expression simultaneously, which is often crucial to understanding sign language, using its attention mechanism for creating tight bounding boxes around classified gestures. The model’s work is later compared with the traditional identification methods of activity recognition. It not only works faster but achieves better accuracy as well. The model achieves overall 82.66% testing accuracy with a very considerable performance of computation with 94.13 Giga-Floating Point Operations per Second (G-FLOPS). Another contribution is a newly created dataset of Pakistan Sign Language for Manual and Non-Manual (PkSLMNM) gestures.

Multimodal signals of high commitment in expert-to-expert contexts

The paper merges research in multimodality with studies in epistemics and discourse analysis, and analyses the ways in which expert speakers multimodally display their knowledge and their degree of commitment toward it. In a corpus of video abstracts where medical researchers orally illustrate their findings published in the British Medical Journal, body signals of high commitment – palm-up-open-hand, headshake, eyelid-closure, and shoulder shrug – are analyzed from a semantic and cognitive point of view as markers of high certainty and obviousness. The differences and relationships among body epistemic markers and their concomitant lexical affiliates, along with their semantic nuances, are illustrated in depth.

Isolated Spinal Accessory Nerve Palsy from Volleyball Injury.

Spinal accessory nerve (SAN) palsy is typically a result of posterior triangle surgery and can present with partial or complete paralysis of the trapezius muscle and severe shoulder dysfunction. We share an atypical case of a patient who presented with SAN palsy following an injury sustained playing competitive volleyball. A 19-year-old right hand dominant competitive volleyball player presented with right shoulder weakness, dyskinesia, and pain. She injured the right shoulder during a volleyball game 2 years prior when diving routinely for a ball. On physical examination she had weakness of shoulder shrug and a pronounced shift of the scapula when abducting or forward flexing her shoulder greater than 90 degrees. Manual stabilization of the scapula eliminated this shift, so we performed scapulopexy to stabilize the inferior angle of the scapula. At 6 months postoperative, she had full active range of motion of the shoulder. SAN palsy can occur following what would seem to be a routine volleyball maneuver. This could be due to a combination of muscle hypertrophy from intensive volleyball training and stretch sustained while diving for a ball. Despite delayed presentation and complete atrophy of the trapezius, a satisfactory outcome was achieved with scapulopexy.

First impression sexual scripts of romantic encounters: Effect of gender on verbal and non verbal immediacy behaviors in American media dating culture

The current study investigates sexual scripts in reality dating shows—in particular, how the gender of the communicator affects the choice of verbal and nonverbal immediacy behaviors aimed at making a first impression. Data were drawn from 331 couples of opposite-sex heterosexual strangers interacting for approximately 30 seconds on two reality dating shows: The Bachelor and The Bachelorette (2012–2019). As a result, a codebook of verbal immediacy cues ( N = 1623) and nonverbal immediacy cues ( N = 3021) was derived. The findings showed that verbal behavior encompassed 11 categories of verbal immediacy cues, while nonverbal behavior included 32 categories of nonverbal immediacy cues. Results also showed gender-related preferences for verbal immediacy behavior; for instance, men were more likely to outline the probability of relationship development and pay compliments; conversely, women were prone to intriguing men to arouse curiosity and interest. As for nonverbal immediacy behavior, men were predisposed to use clothes straightening, while women tended to communicate immediacy through head tilt, shoulder shrug, gaze down, gaze side(s), eyebrow flashes, hand-in-hand, hug, pat, holding hands in front of their bodies, and hair grooming. Nonetheless, the similarities between men and women were found to be greater than the differences. These findings could have wide-reaching implications for theorizing on social and cultural norms, gender stereotypes, and traditional gender roles in intimate relationships in the form of sexual scripts, along with contributing to the study of reality television.

Tourette disorder: A case report.

Tourette disorder: A case report.

Autokinesis illusion in fighter flying revisited

Introduction: Autokinesis refers to the perception of motion which is experienced by an aircrew when he fixates his gaze on a stationary point/source of light in an otherwise completely darkened environment. A study was conducted in the Department of Acceleration Physiology and Spatial Orientation, Institute of Aerospace Medicine to determine the time taken for onset of autokinesis in the disorientation simulator (Air Fox DISO) and the effectiveness of various intervention strategies to break the illusion. Material and Methods: A total of 103 randomly selected fighter pilots participated in the study. They were briefed about the illusion and the various interventions used to counteract it, such as: (a) Shrugging of shoulders without breaking gaze, (b) stretching of arms without breaking gaze, (c) breaking of gaze for 5 s and (d) breaking of gaze for 10 s (if the illusion is not broken after breaking of gaze for 5 s). Time taken for autokinesis to set in and the effectiveness of the interventions used were noted. Subjective feedback from the participating aircrew was also obtained on their experience on autokinesis illusion in active flying through a structured questionnaire. Results: The average time required for onset of the autokinesis illusion in the DISO was observed to be 20.3 ± 15.5 s (range 4.1–121.4 s). Of the 103 aircrew participants, 100 (97.1%) reported that the intervention of stretching of arms was effective, 94 aircrew (91.3%) reported that the intervention of shoulder shrug was effective in breaking the illusion and 99 aircrew (96.1%) were able to counter the illusion by breaking their gaze for duration of 5 s. Autokinesis was experienced in active flying by 17 aircrew, accounting for an incidence of 16.5%. This study reveals that autokinesis involves the interplay of vision, vestibular system, as well as the proprioceptive stimulus in counteracting this illusion. A combination of gaze break and shoulder shrug/arm stretch could be the most appropriate intervention strategy under such circumstances. The operational scenarios conducive for causing this illusion and the physiological basis for the various intervention strategies have been discussed. Conclusion: The autokinesis illusion though considered benign has got significant potential for distraction during operational flying. The intervention strategies discussed in the study are effective in breaking the illusion. The pilot community needs to be aware of the preconditions, mechanism, and effectiveness of the intervention strategies in countering this illusion.

The impact of COVID‐19 lock‐downs for European (female) immunologists – our views as members of the EFIS gender and diversity task force

The impact of COVID‐19 lock‐downs for European (female) immunologists – our views as members of the EFIS gender and diversity task force

Usefulness of ultrasonography for diagnosing iatrogenic spinal accessory nerve palsy after lymph node needle biopsy: a case report

BackgroundSpinal accessory nerve (SAN) palsy is rare in clinical settings. Iatrogenicity is the most common cause, with cervical lymph node biopsy accounting for > 50% of cases. However, SAN palsy after lymph node needle biopsy is extremely rare, and the injury site is difficult to identify because of the tiny needle mark.Case presentationA 26-year-old woman was referred to our hospital with left neck pain and difficulty abducting and shrugging her left shoulder after left cervical lymph node needle biopsy. Five weeks earlier, a needle biopsy had been performed at the surgery clinic because of suspected histiocytic necrotizing lymphadenitis. No trace of the needle biopsy site was found on the neck, but ultrasonography (US) showed SAN swelling within the posterior cervical triangle. At 3 months after the injury, her activities of daily living had not improved. Therefore, we decided to perform a surgical intervention after receiving informed consent. We performed neurolysis because the SAN was swollen in the area consistent with the US findings, and nerve continuity was preserved. Shoulder shrugging movement improved at 1 week postoperatively, and the trapezius muscle manual muscle testing score recovered to 5 at 1 year postoperatively. The swelling diameter on US gradually decreased from 1.8 mm preoperatively to 0.9 mm at 6 months.ConclusionWe experienced a rare case in which US was useful for iatrogenic SAN palsy. Our results suggest that preoperative US is useful for localization of SAN palsy and that postoperative US for morphological evaluation of the SAN can help assess recovery.

Feedback-dependent neuronal properties make focal dystonias so focal.

Focal dystonia, by definition, affects a specific body part; however, it may have a widespread neural substrate. We tested this hypothesis by examining the intrinsic behaviour and the neuronal properties that are modulated by changes in the physiological behaviour of their connections, that is feedback dependence, of the isolated pallidal neurons. During deep brain stimulation surgery in 12 patients with isolated cervical dystonia (without hand involvement), we measured spontaneous as well as evoked single-unit properties in response to fist making (hand movement) or shoulder shrug (neck movements). We measured the activity of isolated neurons that were only sensitive to the neck movements, hand movement, or not responsive to hand or neck movements. The spontaneous firing behaviour, such as the instantaneous firing rate and its regularity, was comparable in all three types of neurons. The neck movement-sensitive neurons had prominent bursting behaviour in comparison with the hand neurons. The feedback dependence of the neck movement-sensitive neurons was also significantly impaired when compared to hand movement-sensitive neurons. Motor-evoked change in firing rate of neck movement-sensitive neurons rapidly declined; the decay time constant was much shorter compared to hand movement-sensitive neurons. These results suggest that in isolated cervical dystonia, at the resolution of single neurons, the deficits are much widespread, affecting the neurons that drive the neck movement as well as the hand movements. We speculate that clinically discernable dystonia occurs when additional abnormality is added to baseline dysfunctional network, and one source of such abnormality may involve feedback.

Motor control integrated into muscle strengthening exercises has more effects on scapular muscle activities and joint range of motion before initiation of radiotherapy in oral cancer survivors with neck dissection: A randomized controlled trial.

BackgroundAccessory nerve shoulder dysfunction is common after neck dissection in oral cancer survivors. This study aimed to investigate the short-term effects of scapular muscle strengthening exercises with motor-control techniques on neck dissection-related shoulder dysfunction in oral cancer survivors before the initiation of radiotherapy.MethodsThirty-eight participants were randomly allocated into the motor-control and regular-exercise groups. Each group received conventional physical therapy and specific scapular muscle strengthening exercises for 1 month immediately after neck dissection. Motor control techniques were integrated with scapular strengthening exercises for the motor-control group. Shoulder pain, active range of motion (AROM) of shoulder abduction, and scapular muscle activities including upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) when performing maximal voluntary isometric contraction (MVIC) and scapular muscle exercises were evaluated at baseline and after 1 month of training.ResultsBoth groups reduced shoulder pain and increased muscle activity of maximum voluntary isometric contraction (MVIC) of each muscle after the intervention. Increased AROM of shoulder abduction was only observed in the motor-control group (95% CI 3.80 to 20.51, p = 0.004). Relative to baseline evaluation, muscle activities of UT decreased in the motor-control group when performing shoulder shrug with 1-kg weight (95% CI -33.06 to -1.29, p = 0.034). Moreover, the SA activity decreased in the motor-control group (95% CI -29.73 to -27.68, p<0.001) but increased in the regular-exercise group (95% CI 28.16 to 30.05, p<0.001) when performing shoulder horizontal adduction and flexion.ConclusionEarly strengthening exercise with motor control techniques has greater benefits for improving AROM of shoulder abduction, muscle economy, and reducing compensatory scapular muscle activities in patients with neck dissection-related shoulder dysfunction before the initiation of radiotherapy.

Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury

Preoperative diagnosis of long thoracic nerve (LTN) palsy is important for shoulder reconstruction after a traumatic brachial plexus injury (BPI). In the present study, we developed an objective diagnostic method for LTN palsy for patients with traumatic BPI. This is a retrospective review of 56 patients with traumatic BPI who had been receiving treatment at a single institution for over 8 years. The patients were divided into 2 groups: an LTN palsy group (n = 30) and a no palsy control group (n = 26). The LTN palsy group had 21 different palsy types with 4 and 5 C5-7 and C5-8, whereas the no palsy group had 18 different palsy types with 5 and 3 C5-6 and C5-8, respectively. Preoperative plain anteroposterior radiographs were taken in shoulder adduction and shrug positions. Scapulothoracic (ST) upward rotation and clavicle lateral (CL) rotation angles were measured on X-rays. The differences between the adduction and shrug positions for the respective angles were calculated and defined as ΦST and ΦCL, respectively. The differences in the ΦSTand ΦCL values due to the presence or absence of LTN palsy were examined, the cutoff values of ΦSTand ΦCLfor the diagnosis of LTN palsy were determined, and further sensitivity and specificity were calculated. Both ΦSTand ΦCLwere significantly decreased in the LTN palsy group compared with the no palsy control group. The sensitivity and specificity for LTN palsy were 0.833 and 1.000 for ΦSTand 0.833 and 0.840 for ΦCL, respectively, when the cutoff value was set as ΦST= 15° and ΦCL≤ 24°. Dynamic shrug radiographs provide a useful objective diagnosis of LTN palsy after traumatic BPI.

Real-time Ultrasound-guided Puncture of Subclavian Vein for Chemo-port Implantation

Introduction: There is no consensus regarding preferred site for central vein cannulation. [1] The jugular vein is the most “popular site” for central vein cannulation and is the “preferred site” for temporary hemodialysis. [2] The subclavian vein is less “infection-prone” but more likely to cause pneumothorax. [3] In case of chemo-port implantation, anatomical landmark puncture (ALP) of subclavian vein or cephalic vein exploration (CVE) at delto-pectoral groove have been the more “convenient” and “preferred” methods to avoid unaesthetic two incisions and visible subcutaneously-tunneled catheter. Recent evidence suggests that real-time ultrasound guided puncture (UGP) of subclavian vein could lower pneumothorax rate from 1-6% to 0%. [4] The safety, successful cannulation rate and pitfalls of this new procedure are our concerns. Methods: From Oct.13rd, 2018, all patients scheduled for chemo-port implantation were enrolled for clinical trial of UGP for subclavian vein cannulation. The exclusion criteria included surgical site skin infection or tumor invasion, uncorrectable coagulopathy and known occluded central veins. The preoperative sonography reveals diameter of target vein (DTV), skin-to-anterior wall of target vein distance (SAVD) and diameter change along with inspiration. The cancer type, laterality of chemo-port, positioning and body mass index (BMI) of patients, attempts of puncture, pain score during puncture, conversion rate and procedure-related complications were recorded. Results: Total 77 patients, 88.3% female, aged 31-81(mean 54.6) underwent UGP of deep vein at subclavian region for chemo-port implantation. 59.7% of target veins were at left side and they included 68 subclavian veins, 5 axillary veins and 4 cephalic veins at clavipectoral fascia. 98.7% of operations were performed under local anesthesia. The diversity of cancer types included 47 breast cancer, 10 colon cancer etc. BMI ranged from 18.1 to 33.4 ( 24.2± 3.6). DTV and SAVD were 8.5±1.7 mm and 19.4±4.7 mm respectively. Severe subclavian vein collapse during inspiration was found in 25% patients. 54.4% patients were put on Trendelenburg position, 7.4% with shoulder cushioned and none with shoulder shrugging. The success rate of UGP was 90.9% with 6.5% converted to ALP and 2.6% to CVE. The mean attempts of UGP was 2.0±1.9. The pain score during UGP was 3.5±2.0. The total procedure time was 27.7±8.0 minutes. There is no statistically difference between failed group and success group in age, BMI, SAVD, but there is difference in DTV (p=0.0247). [Table 1] There was one pneumothorax (1.3%) found after operation and remitted spontaneously without tube drainage. The Kaplan-Meier curve of patient survival and function of chemo-port has been 100% without re-intervention due to infection or obstruction. Conclusion: The UGP for subclavian vein cannulation is a new technique for a surgeon familiar with ALP. It has opened the 3rd eye of the surgeon to see the advancement of the needle tip and the dramatic change of vein diameter along with the inspiration in our 25% patients. The success rate and complications are fair in our study. The DTV is the main factor for cannulation failure.Table 1comparison of failure group and success groupTable 1comparison of failure group and success group Disclosure: Nothing to disclose

Long-term follow-up results of 550 cases of spastic torticollis treated with modified Foerster-Dandy operation

Objective To investigate the long-term efficacy and complications of modified Foerster-Dandy operation in the treatment of spasmodic torticollis (ST). Methods A total of 550 cases of ST admitted to Neurosurgery Department of China-Japan Friendship Hospital from April 2005 to April 2013 were retrospectively enrolled into this study. All patients were treated with modified Foerster-Dandy operation, in which occipitocervical posterior median approach was used without opening of occipital squama and foramen magnum. Limited laminectomy, endoscope-assisted bilateral subdural accessory nerve and C1 spinal nerve root cutting and selective partial cutting of anterior and posterior roots of C2-4 spinal nerve were conducted. The international Tsui scale was used to evaluate the efficacy post operation. We also analyzed the complications occurring following the operations. Results All patients were followed up for 60-156 months, with an average of 117.0±5.5 months. The median improvement rate of spasticity at 6 months, 12 months and the latest follow-up was 73.6% (54.7%, 86.4%), 70.2% (48.8%, 85.1%) and 73.2% (51.1%, 88.5%), respectively. The Tsui score before operation was 17.2 (13.6, 20.6). However, at 6 months, 12 months and the latest follow-up, the Tsui scores were 4.6 (2.2, 7.3), 4.9 (2.6, 8.1) and 4.3 (2.0, 7.5), respectively, which were significantly lower than those prior to operation (all P<0.05). However, 30 (5.5%) cases had neck rotation weakness, 34 (6.2%) reported shoulder shrug weakness, 32 (5.8%) had limited arms abduction, 45 (8.2%) developed long-term neck back pain and numbness, 11 (2.0%) reported neck circumference narrowing, and 62 (11.3%) suffered from dysphagia. Among them, no obvious improvement was achieved in 5 cases with neck rotation weakness and 9 cases with dysphagia. All the other complications were relieved to various degrees during the follow-up period after rehabilitation training. During the follow-up, spasm recurrence to various degrees was reported in 25 (4.5%) cases. Conclusion Modified Foerster-Dandy operation is a safe and effective surgical therapy for patients with ST. Key words: Spasmodic torticollis; Neurosurgical procedures; Treatment outcome; Postoperative complications; Foerster-Dandy operation

The role of pallidum in the neural integrator model of cervical dystonia

Dystonia is the third most common movement disorder affecting three million people worldwide. Cervical dystonia is the most common form of dystonia. Despite common prevalence the pathophysiology of cervical dystonia is unclear. Traditional view is that basal ganglia is involved in pathophysiology of cervical dystonia, while contemporary theories suggested the role of cerebellum and proprioception in the pathophysiology of cervical dystonia. It was recently proposed that the cervical dystonia is due to malfunctioning of the head neural integrator – the neuron network that normally converts head velocity to position. Most importantly the neural integrator model was inclusive of traditional proposal emphasizing the role of basal ganglia while also accommodating the contemporary view suggesting the involvement of cerebellum and proprioception. It was hypothesized that the head neural integrator malfunction is the result of impairment in cerebellar, basal ganglia, or proprioceptive feedback that converge onto the integrator. The concept of converging input from the basal ganglia, cerebellum, and proprioception to the network participating in head neural integrator explains that abnormality originating anywhere in the network can lead to the identical motor deficits – drifts followed by rapid corrective movements – a signature of neural integrator dysfunction. We tested this hypothesis in an experiment examining simultaneously recorded globus pallidal single-unit activity, synchronized neural activity (local field potential), and electromyography (EMG) measured from the neck muscles during the standard-of-care deep brain stimulation surgery in 12 cervical dystonia patients (24 hemispheres). Physiological data were collected spontaneously or during voluntary shoulder shrug activating the contralateral trapezius muscle. The activity of pallidal neurons during shoulder shrug exponentially decayed with time constants that were comparable to one measured from the pretectal neural integrator and the trapezius electromyography. These results show that evidence of abnormal neural integration is also seen in globus pallidum, and that latter is connected with the neural integrator. Pretectal single neuron responses consistently preceded the muscle activity; while the globus pallidum internus response always lagged behind the muscle activity. Globus pallidum externa had equal proportion of lag and lead neurons. These results suggest globus pallidum receive feedback from the muscles or the efference copy from the integrator or the other source of the feedback. There was bi-hemispheric asymmetry in the pallidal single-unit activity and local field potentials. The asymmetry correlated with degree of lateral head turning in cervical dystonia patients. These results suggest that bihemispheric asymmetry in the feedback leads to asymmetric dysfunction in the neural integrator causing head turning.

My Father, My Patient.

My Father, My Patient Michael Rezak Background "Education is the only thing that they can't take away from you." These were the words my father would utter innumerable times during my childhood and adolescence. Over the years I came to know the meaning of those words and why this conviction ran so deeply inside of him. A man who survived the anti–Semitism of pre–World War II Poland and then the horrors of the Holocaust deserved better than to suffer from a physician error that led him to become totally dependent on others for his daily care. How could this independent, strong and intelligent man who had survived unspeakable horrors in the concentrations camps, in an instant become, in essence, my third child? Before this event, other than using my neurological specialty knowledge in movement disorders to manage his mild Parkinson's tremor, I had played mainly a supervisory role in his healthcare. My [End Page 22] mother, his wife of over fifty years, died six months earlier and my father had just moved to Chicago to be closer to his children. Upon his arrival in Chicago, I arranged his visits to the primary care physician—mainly to manage the warfarin he was taking because of atrial fibrillation—and to an excellent dermatologist because of a new skin lesion. A superficial skin cancer was diagnosed. Despite my suggestions to the contrary, he informed me that he was going to Florida for the winter and would meet with relatives who would be there in a few weeks. He said he would have the skin lesion taken care of there. I wasn't happy about the decision since we didn't know anyone in the medical community there, but being the smartest guy I knew, I respected his autonomy. I typically called my father frequently, but that day I could not reach him. This was unusual, and although I had my concerns, I hoped he was out enjoying life. I got the call that afternoon from a neighbor who relayed that he was found wandering in the parking lot of his building in his pajamas. That neighbor drove him to the hospital. On a moment's notice my sister and I attempted to procure a flight to Miami that somehow we were miraculously able to arrange during this Thanksgiving holiday period. He was still in the emergency department when we arrived many hours later. I found him in restraints on a gurney in a hallway without supervision, fighting to get out of those "handcuffs" and entirely delusional. The tattooed numbers on his arm stood out like a neon sign, 160247. I had seen these numbers all of my life, and it was painful each time I thought about how the Nazis held him down and put these numbers on his arm to mark him like cattle on a farm. Was he once again reliving that experience? Previously, he didn't speak much about the details of his captivity and torture, and I didn't ask too many questions to spare him from reliving those memories, but I knew that the experiences he endured never left his consciousness. In my heart, I knew he wanted his children to know what happened so it would never happen again. I should have asked more questions, but I was afraid of hearing the answers. As my gaze fell upon this disoriented struggling man, I thought how painfully ironic for me, his son the neurologist, to have his father suffer an iatrogenically induced embolic shower to both hemispheres and the midbrain, rendering him cognitively impaired, impulsive and delusional. In the setting of atrial fibrillation, why was anti-coagulation stopped for a simple resection of this skin cancer? The surgeon's response was an indifferent shoulder shrug, and he began citing statistics indicating that the risk of stroke was minimal in atrial fibrillation. I replied that the risk was 100% for my father. He walked away to continue his life as it always had been, but life would never be the same for us. Dilemma A multitude of ethical dilemmas arose for me during the next ten years of his life as I, de facto, became...

Speed limits for the animal kingdom

![Graphic][1] Ask anyone ‘what is the fastest animal on earth?’. A guaranteed popular response will be ‘a cheetah!’. But, if you ask ‘why are cheetahs the fastest animals?’, you might receive some quizzical looks and uncertain shoulder shrugs. Until recently, most scientists also