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Levodopa Reduces Muscle Tone and Lower Extremity Tremor in Parkinson’s

Disease

Article  in  The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques · December 1995
DOI: 10.1017/S0317167100039470 · Source: PubMed

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 Levodopa Reduces Muscle Tone and
Lower Extremity Tremor in Parkinson's
Disease
Anne Burleigh, Fay Horak, John Nutt and James Frank

ABSTRACT: Objective: We have quantified the effects of levodopa treatment in Parkinsonian subjects
during maintained stance. Methods: Electromyographic muscle activity during quiet stance was assessed in
subjects with Parkinson's disease, who exhibited a fluctuating response to levodopa, and in age-matched
control subjects. Stance stability was also assessed from mean displacement and velocity of the center of
pressure excursions during stance. Results: Lower extremity and trunk muscles showed high amplitude
activity in all Parkinson's subjects when "off", and a 4-5 Hz tremor in three of these subjects. When "on",
the amplitude of muscle activity was reduced in the distal muscles more than the proximal, while tremor
was suppressed in all muscles. Corresponding to the excessive muscle activity, the Parkinson's subjects had
increased velocity and variability of velocity in the anterior-posterior center of foot pressure excursions, but
the mean displacement of the center of pressure excursion was not different from the controls. The velocity
of center of pressure excursions in the Parkinson's subjects "on", approached those of the control subjects
suggesting that the excessive distal muscle amplitude and tremor contributed to the high velocity of the
center of pressure. Conclusions: These findings suggest that dopaminergic systems are involved in the reg-
ulation of muscle tone during stance. Depletion of dopaminergic transmission results in increased muscle
tone and tremor in the lower extremities which may contribute to changes in posture and stability.

RESUME: La L-dopa diminue le tonus musculaire et le tremblement des membres infeYieurs dans la mal-
adie de Parkinson. Objectif: Nous avons quantifie les effets du traitement par la L-dopa chez des parkinsoniens en
position debout. Methodes: Nous avons evalu6 l'activite musculaire par electromyographic chez des parkinsoniens
en position debout stable qui prfsentaient des fluctuations dans la reponse a la L-dopa et chez des sujets controles
appartes pour 1'age. La stability de la posture 6tait 6galement 6valu6e par le defacement moyen et la v61ocit6 des
oscillations du centre de pression pendant la station debout. Risultats: Les muscles des membres infeiieurs et du
tronc prdsentaient une activity de haute amplitude chez tous les parkinsoniens quand ils n'6taient pas sous l'effet de
la L-dopa et un tremblement de 4-5 Hz chez trois de ces sujets. Quand ils gtaient sous l'effet du medicament,
l'amplitude de l'activit6 musculaire 6tait diminuee de fajon plus marquee dans les muscles distaux que proximaux,
alors que le tremblement 6tait supprime' dans tous les muscles. Les parkinsoniens prgsentaient un accroissement de
la v61ocitg et de la variability de la velocity des oscillations ant6ro-post6rieures du centre de pression du pied corre-
spondant a l'activite' musculaire excessive, mais le d6placement moyen du centre de pression n'eteit pas different de
celui des contr61es. La v61ocit6 des oscillations du centre de pression chez les parkinsoniens en pdriode d'effet de la
L-dopa dtait presque identique a celle des controles, sugg^rant que l'amplitude excessive des muscles distaux et le
tremblement contribuaient a la haute v61ocit6 du centre de pression. Conclusions: Ces observations suggerent que
les systemes dopaminergiques sont impliqufis dans la regulation du tonus musculaire pendant la station debout.
L'epuisement de la transmission dopaminergique mene a I'augmentation du tonus musculaire et au tremblement
des membres inf^rieurs, ce qui peut contribuer aux changements dans la posture et la stability.

Can. J. Neurol. Sci. 1995; 22: 280-285

Parkinson's disease (PD) is characterized clinically by rest- have quantified the effects of L-dopa treatment on the baseline
ing tremor, muscle rigidity, bradykinesia and disturbed postural muscle activity and tremor in lower extremity and trunk muscles,
responses. 1 These motor disturbances are related to loss of
dopamine in the nigrostriatal system. Treatment with the
dopamine precursor, levodopa (L-dopa) typically improves the From the R.S. Dow Neurological Sciences Institute of GSH & MC (A.B., F.H.); the
Departments of Physiology (A.B., F.H.), and Neurology (F.H., J.N.) at Oregon Health
motor performance of persons with PD. Although there is evi- Sciences University, Portland, Oregon; the Department of Kinesiology (J.F.) at
dence that L-dopa is more effective in treating limb dysfunction University of Waterloo, Waterloo, Ontario.
than axial symptoms, 23 quantification of the effects of L-dopa
RECEIVED JANUARY 2 , 1 9 9 5 . ACCEPTED IN FINAL FORM MARCH 2 9 , 1 9 9 5 .
Reprint requests to: Fay Horak, R.S. Dow Neurological Science Institute, 1120 N.W.
on muscle activity and stability during stance is lacking. We 20th Avenue, Portland OR 97209-1595 USA.

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 LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES

and on stance stability as assessed from mean displacement and C O P 4 5 thus provided a measure of stability that could be
velocity of the center of pressure excursions during stance. directly compared across Parkinson's and control subjects. A
Fourier analysis of the COP displacement data was used to
METHODS determine if tremor was solely responsible for differences in
the velocity parameters between the PD and control subjects.
Eleven subjects (6 male, 5 female; age 61.6 y ± 4.5) with
idiopathic Parkinson's disease (Hoehn and Yahr stages III to IV A paired Student's t-test was used to compare mean EMG
when "off") and eleven neurologically normal, age-matched amplitude between PD subjects " o f f and "on". Paired t-tests
controls participated in the study. The mean duration of disease were also used to compare mean amplitude of excursion, mean
in the subjects with Parkinson's disease was 13 years, ranging velocity, and mean pathlength of COP between PD subjects
from 6 to 35 years. Three PD subjects had clinically apparent "off' and "on". An unpaired t-test was used to compare mean
tremor in both hands. Subjects with PD reported to the laborato- amplitude of excursion, mean velocity, and mean pathlength of
ry in the morning, having withheld their morning L-dopa/car- COP between PD subjects and control subjects. A p-value of
bidopa (Sinemet®), and were initially tested when "off' (i.e., off less than 0.05 was accepted for statistical significance. A coef-
medication and parkinsonian features prominent). Subjects then ficient of variation for the COP velocity was calculated for each
took their normal L-dopa dose and were re-tested approximately subject group to control for differences as the mean velocity
one hour later when "on" (i.e., on medication and parkinsonian increased.
features diminished). During the testing sessions, subjects stood
comfortably on a dual-plate platform, with one foot centered on RESULTS
each plate, arms folded in front of the body and gaze directed
forward to the laboratory wall. Subjects had come to the labora- When "off', the EMG activity of the PD subjects was exces-
tory to participate in another experiment, thus the data being sive in all muscles recorded during quiet stance. High phasic
presented in this paper result from single trials recorded for activity and spiking of the EMG activity was a common feature
three seconds as a baseline measure of independent stance. All in all PD subjects, but was not seen in control subjects, as illus-
subjects were able to stand independently for longer than the trated by the representative PD and control subjects in Figure 1.
reported three second interval. Two subjects with PD later A Fourier transform revealed multiple frequency components in
returned for repeat testing, to verify the repeatability of the EMG's of three PD subjects (FigureIB). Administration of L-
results. dopa resulted in significant reduction of excess amplitude in the
distal lower extremity muscles but not the proximal lower
Surface electrodes were used to record electromyographic extremity muscles or paraspinals. L-dopa did not significantly
activity (EMGs) unilaterally from the tibialis anterior, medial change the frequency components of the EMG. When "on", the
gastrocnemius, rectus femoris, biceps femoris, and paraspinals. mean amplitude of the tibialis and gastrocnemius was signifi-
Skin impedance was less than 15 KOhms for all subjects, with cantly reduced (p < 0.01) in the PD subjects with the administra-
electrodes kept in place throughout the entire period of testing. tion of L-dopa (Figure 2), however, the spike-like firing pattern
The EMGs were amplified, band-pass filtered (70-2000 Hz) and persisted. There was no significant reduction in the mean ampli-
full-wave rectified. The mean amplitude and standard deviation tude of the more proximal rectus femoris, biceps femoris, or
of muscle activity during quiet stance over the full 3 second paraspinal muscles, but there was a trend for EMG amplitude in
period was quantified using a Macintosh program (Axograph) these muscles to decrease after the administration of L-dopa
for wave analysis. The mean amplitude and standard deviation (Figures 1 and 2). The mean percent reduction in EMG activity
of one second intervals over the full period was also quantified was 46.3 ± 16.25% for tibialis (p < 0.01), and 30.3 ± 16.25% for
to verify that the mean EMG level was stable over the 3 sec- gastrocnemius (p < 0.01), but only 1.42 ± 4.2% for the rectus
onds. Fourier analysis of the individual muscle EMGs over the femoris (ns), 25.27 ± 17.54% for biceps femoris (ns), and 12.92
three seconds was used to determine the presence and frequency ± 4.87% for paraspinals (ns). There was no correlation between
of tremor. disease severity or duration and the percent reduction in the
Surface forces were recorded using strain gauges mounted EMG amplitudes quantified in the PD subjects when "on".
in the platform, and the anterior-posterior displacement of the Although a direct comparison of EMG amplitudes between con-
center of foot pressure (COP) was calculated for the full 3 sec- trol and PD subjects is not possible, the mean amplitude of
ond period. The velocity of COP was calculated as the first EMGs for the group of PD subjects "off' far exceeded EMG
derivative of the filtered COP displacement data. The mean amplitudes recorded in control subjects with similar electrode
anterior and mean posterior excursion of the COP and the path- placement and impedance (Figure 2). Also, the phasic, spike-
length over time were quantified to determine if the amount of like firing pattern was unique to the PD subjects since it was
sway was greater in the PD subjects compared to the controls. never observed in the control subjects. Administration of L-dopa
Both anterior and posterior excursions were expressed as posi- reduced mean EMG in the PD subjects "on", with levels
tive change with respect to foot center. This allowed the mean approaching those measured in control subjects. The effect was
amplitude of excursion about baseline to be quantified. The reproducible as indicated by a similar reduction of distal muscle
COP velocity data was rectified and the mean and standard activity seen in the two Parkinson's subjects who returned to the
deviation of the velocity were quantified. Velocity was there- laboratory for repeat testing. Furthermore, analysis of one sec-
fore expressed as a positive value of mean rate of change of the ond intervals in all subjects confirmed that the muscle activity
COP with respect to the foot center. Increases in the velocity remained stable over the full three seconds since there was no
parameters correspond to decreases in stance stability. 4 difference between the values obtained for the one second inter-
Information from the excursion and velocity of excursion of the vals and the full three second period.

Volume 22, No. 4 — November 1995 281

THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES

Off medication On medication Elderly Control

200 uv lOOuV
Tibiali
AJUVJUL u yj

Gastroc 100UV
•/AJM^UCAJWA*. JUMA*A*V«I

Rectus Fem. , lOOuV

Biceps Fem. I , i
100 uV

Paraspinals
lOOuV

I—>—i—•—i—'—i—'—i—•—i
0 200 Time(ms) 800

B.

° A
0.40 == A A
Tibialis o A
/ A _/ \
-^- V v v^ ^ M « ^ k _ ^ - w ~ _ ^

^ \\
° A l l
0.03 * A/ \A AM
Paraspinals
~ / v v v ' WL ^ 4 W ^ _
ft A Uiif

1 1—I M i l l ]
- i 1 1 1 1 1 1 1 1 | 1 1
i '
10 100 1 Frequency 10 100 I 10 100

Figure J: (A) EMG activity recorded from a Parkinson's subject off and on L-dopa medication and an elderly control subject during quiet stance. The PD
subject exhibits high tonic activity in all muscles. Only the tibialis and gastrocnemius activity is clearly reduced with L-dopa medication. Tire 200 pV c
bration applies to the tibialis EMG for the PD subject; all other calibration bars apply to the PD and control subject EMGs. (B) Corresponding Fourie
analysis of the tibialis and parqaspinal EMGs demonstrating multiple high-frequency components in the PD subject, that are not affected by L-dopa.

In addition to high amplitude activity, three PD subjects also ferent from controls (Figure 4A), thus, the PD subjects did not
exhibited a distinct 4-5 Hz tremor in the lower extremity mus- exhibit a larger amplitude sway than the controls during stance.
cles and paraspinals. Although not apparent on clinical examina- However, both the mean velocity of the COP excursion (Figure
tion, the tremor was in all muscles recorded in two subjects, 4B) and the standard deviation of the velocity were significantly
while in the third, tremor was recorded only from the tibialis greater in the PD subjects "off' compared to controls (p < 0.02)
and rectus femoris. Administration of L-dopa suppressed the and the PD subjects "on" compared to controls (p < 0.05),
tremor activity in all lower extremity muscles and the (Table). When "off', the velocity measures of the PD subjects
paraspinals, but reduced the mean amplitude of tonic EMG were almost 10 times greater than controls, even though the
activity only in the tibialis and gastrocnemius (Figure 3). amplitude of the COP excursion was not significantly different.
Analysis of the COP suggested that the high amplitude and Corresponding to the higher velocity without increases in the
phasic muscle activity in the PD subjects contributed to a faster amplitude of COP excursion, the mean pathlength was significantly
and less predictable excursion of the body during stance. The mean greater in the PD subjects "off compared to controls (p < 0.02)
amplitude of the COP in the PD subjects was not significantly dif- and the PD subjects "on" compared to controls (p < 0.05),

282
 LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES

Figure 2: Mean amplitude and standard error of EMC activity record-

Gastrocnemius Tibialis ed in eleven Parkinson's subjects off L-dopa medication (Off = black
20 rpsO.oT 40 ip^O.Ol1 bar) and on medication (On = clear bar), and Normal Healthy Elderly
controls (NHE = gray bar). When "on", a significant reduction (p <
0.01) of tibialis and gastrocnemius activity in the PD subjects was veri-
fied with a Student's t-test and EMG amplitudes approached those
measured in NHE. L-dopa did not significantly reduce proximal muscle
tone in PD subjects. No statistical comparison can be made between
EMC amplitudes of PD subjects and the control subjects, however, the
mean values demonstrate that tonic activity is consistently higher in the
PD subjects "off" and approaches control values when "on ".

Off On NHE
fl
Off On NHE
(Table). To verify that the significant differences in the standard
deviation of velocity were not due only to increases in the mean,
a coefficient of variation was calculated, with differences still
existing between the PD subjects and controls (percent variabil-
ity with respect to mean; control = 60%, off = 119%, on =
Biceps Fem. Rectus Fem. Paraspinals 101%). When "on", all PD subjects showed a reduction in the
35 velocity of the COP excursion, and the group mean approached
that of the controls. Five PD subjects, when "on", had velocity
measures within the normal control range.

DISCUSSION

Two distinct observations have been presented with respect

to the effects of oral L-dopa on postural mechanisms in

Off On NHE Off On NHE

m
Off On NHE
Parkinson's disease. First, PD subjects exhibit excessively high
amplitude, phasic activity in lower extremity and trunk muscles
which is significantly reduced in the distal but not proximal
lower extremity and trunk muscles by administration of L-dopa.
Second, the 4-5 Hz tremor in lower extremity and trunk muscles
during stance was abolished by L-dopa, while 8-20 Hz

A. Off medication On medication B. Off medication On medication

Tibialis

TJUUULA L_AL*JU- /lwJ\_

100 uv]
Gastroc
-<M-«wW"fr*W«WV*rt—<\' I H ^ W I I K W W '

Rectus Fem
l^U^W^^ AWVWUAMA, -^»^>.

Biceps Fem.

u vJUjfcAwCuA^WwUfy^^

LL
-1
i—i—'—i—'—i—'—i—'—i—i
i ri — i — ' — r —T—>—T—'—i—i I—i i i iiui|—i i i Mini—i

1 10 100 1 10 100
Frequency (Hz) Frequency (Hz)
0 200 Time(ms) 800 0 200 Time (ms) 800

Figure 3: (A) EMG activity recorded from a Parkinson's subject off and on L-dopa medication during quiet stance; (B) corresponding Fourier analysis
of the EMC. A 4-5 Hz tremor is present in all muscles when "off", but suppressed when "on ". The 100 pVcalibration bar applies to all muscles.

Volume 22, No. 4 — November 1995 283

THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES

in the velocity of the anterior-posterior COP excursion for all

Table: Center of Pressure Measures and Significance.
PD subjects. Although the PD subjects do not exhibit a larger
Group Amplitude S.D. of Amp. Velocity Pathlength excursion of the COP during stance, the velocity is faster and
(cm) (cm/s) (cm) less predictable. These findings are consistent with the notion
OFF 1.12 0.68 9.65 31.11 that a stiff system oscillates faster about a point of equilibrium.
(1.22) (0.75) (10.84) (34.46) The increased variability in the velocity measures may represent
a disruption in a constant control signal for maintenance of
ON 1.26 0.76 6.56 16.89 stance stability. Whether the baseline activity of the muscles
(1.14) (0.77) (9.61) (19.34) contributes to the instability or is a result of instability is uncer-
NHE 0.93 0.26 1.08 2.98 tain, but the abnormal spike-like EMG and tremor activity in the
(1.88) (0.23) (0.61) (1-90) PD subjects suggests that the muscle activation contributes to
Off vs. On ns ns ns ns the instability. The flexed-posture common in PD, may con-
tribute to the excess muscle activity, however, when normal sub-
Off vs. NHE ns ns p < 0.02 p < 0.02 jects stand in a similar flexed-posture, excessive muscle activity
On vs. NHE ns ns p < 0.05 p < 0.05 is not observed.
NHE = elderly controls, OFF = Parkinson's subjects off L-dopa medi- The output projections of the basal ganglia are somatotopi-
cation, ON = Parkinson's subjects on L-dopa medication. Measures are cally organized primarily from the internal globus pallidus and
expressed as group means and (standard deviations). substantia nigra pars reticulata to the thalamus and the peduncu-
lopontine tegmental region of the brainstem.7 We propose that
there may exist descending brainstem projections involved in
components of phasic activity were unaffected by L-dopa. These the regulation of postural muscle tone; while thalamocortical-
observations suggest that dopaminergic systems, in part, regu- spinal projections with a dopaminergic dependence may be
late motor neuron activity for muscle tone during stance.6 The involved regulation of distal muscle tone and the 4-5 Hz tremor
increased muscle activity corresponds to an increased variability generation.

A. Anterior-posterior COP excursion

Off medication On medication Elderly Control

Posterior

1000 2000 msec

B. Velocity of anterior-posterior COP excursion

Off medication On medication Elderly Control

Anterior _
JlOcm/s
TlO cm/s
^M :H^jt#f^^
Posterior

r-
0 1000 2000

Figure 4: (A) Anterior-posterior COP recorded from a Parkinson's subject off and on L-dopa medication and an elderly control subject during quiet
stance. The dashed lines indicate the mean amplitude of excursion from anterior to posterior which is not significantly different between the PD and
control subjects. (B) Corresponding velocity of the COP. The dashed lines indicate the mean velocity of the anterior excursion and the posterior excur-
sion which is significantly greater in the PD subjects compared to the control.

284
 LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES

Support for the role of a dopaminergic influence on distal L-dopa. Quantification of the velocity parameters of the COP
limb muscle tone comes from both animal and human studies. provides a tool to discriminate postural stability which may be
Increases in distal muscle tone following disruption of the related to high amplitude, phasic muscle activity during stance.
dopaminergic system of the BG have been previously quantified
in animal models of PD including the MPTP treated primates8 ACKNOWLEDGEMENTS
and monoamine depleted 8 or 6-hydroxydopamine (6-OHDA)
We thank our subjects who so willingly participated in this study.
lesioned rats.9 EMG activity of the gastrocnemius and tibialis is This research was supported by a grant from the National Institute on
increased when dopaminergic transmission is reduced. 9 Aging (AGO-6457) awarded to Fay Horak, and a grant from the
Although these animal studies have not quantified changes in Foundation for Physical Therapy awarded to Anne Burleigh.
proximal muscles, they do suggest that the dopaminergic system
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Volume 22, No. 4 — November 1995 285