Vigor and the LDR in Parkinson Disease
Vigor and the LDR in Parkinson Disease
Parkinson disease (PD) is a common disorder in which reduced speed of movement results from
 inadequate brain production of the chemical dopamine. The most effective treatment for PD is
 the drug levo-dopa, which partially replaces brain dopamine. Despite decades of successful
 use, how levo-dopa improves speed of movement in PD is not understood. This observational
 study recruits participants who have been prescribed levo-dopa by their treating physicians.
 Before their first dose, immediately after their first dose and later, when their dose has
 been stabilized, they will engage with the research team to participate in a few simple
 experiments to measure speed, grip strength, tremor, and stability (on and off of treatment).
 The purpose of these experiments is to understand how levo-dopa treatment in Parkinson
 disease enhances movement speed. An important but not understood component of levo-dopa
 action, the Long Duration Response (LDR), lasts for days to weeks. A basic function of
 dopamine signaling in the brain is modulation of motivation - the coupling between effort and
 action values. These experiments will determine if the LDR is associated with relative
 normalization of motivation function in the brain. The motivation behavior of recently
 diagnosed PD participants will be examined before and after treatment with levo-dopa to
 determine if the magnitude of the LDR is correlated with improvements in motivation behavior.
Dopamine replacement therapy (DRT) is the standard symptomatic treatment for early to
 moderate Parkinson disease (PD). In early to moderate PD, the most important DRT component is
 the Long Duration Response (LDR), a pharmacodynamic effect that builds up over the course of
 days-weeks and can be induced by dopamine agonists. Despite its effectiveness, DRT actions
 are poorly understood and the basis of the LDR is unknown. As the LDR wanes in advancing
 disease, PD patients develop troublesome motor fluctuations and increasing disability.
 Improved understanding of the LDR has the potential to prolong the duration of its effects
 and could have a significant positive effect on clinical practice.

 The kinetics of the LDR suggest long-term plastic changes in striatal function. Recent
 studies of striatal dopamine actions in PD subjects and experimental animals indicate that
 striatal dopaminergic neurotransmission regulates "vigor," the force, velocity, or amplitude
 of actions. Vigor is closely allied to the concept that striatal dopaminergic
 neurotransmission mediates motivation, which involves the assessment of act utility and the
 appropriate scaling of actions to perceived rewards. Recent theoretical and experimental
 results suggest that tonic striatal dopamine signaling, mimicked by dopamine agonist
 administration, is a key determinant of movement vigor. Convergent clinical pharmacologic and
 experimental data lead to a strong hypothesis that the LDR results from chronic DRT partially
 restoring motivational coupling of effort to perceived reward and movement vigor. Prior
 experiments examining vigor in PD subjects did not take the LDR into account, resulting in
 incomplete examinations of the role of vigor deficits in PD.

 Recent non-human primate work on the control and vigor of saccadic eye movements indicates
 the existence of basal ganglia circuit changes that stably encode motor action values for
 prolonged periods. Striatal dopaminergic neurotransmission is critical for establishing this
 remarkably stable form of value-action coupling. This phenomenon is a plausible circuit level
 mechanism underlying the LDR.

 Our long-term goal is to understand the clinically relevant actions of DRT. The primary
 objective of our proposal is to test the hypothesis that the LDR results from partial
 restoration of normal action vigor by reinstating the link between motivation and effort. Our
 secondary objective is to explore potential mechanisms underlying the LDR. The rationale for
 these experiments is that better understanding of the LDR, a clinically crucial component of
 DRT action, will lead to improved symptomatic therapy.

 We will study recently diagnosed PD subjects. All subjects will undergo standard evaluations
 of clinical, cognitive, and motivational features. Subjects will perform incentive motivation
 tasks assessing movement vigor in response to monetary incentives. Two complementary tasks,
 one based on modulation of movement velocity and one based on modulation of grip strength,
 will be employed. To assess whether the recently described stable action-value coupling for
 saccades is relevant to the LDR, subjects will perform a task that measures saccadic eye
 movement vigor in response to stable value signals learned prior to LDR induction. Subjects
 will perform all tasks before and after LDR induction in both the "practical off" and
 post-acute treatment states.

 Specific Aim 1: To use incentive motivation tasks to evaluate the coupling between motivation
 and movement vigor in recently treated PD subjects before and after LDR induction.

 Hypothesis 1A: LDR induction will result in partial restoration of movement vigor in response
 to monetary incentives in PD subjects in the "practical off" state.

 Hypothesis 1B: The magnitude of partially restored movement vigor in response to monetary
 incentives will correlate with reduced bradykinesia in PD subjects in the "practical off"
 state.

 Hypothesis 1C: Identical effects will be found with an incentive motivation task based on
 movement amplitude and one based on grip strength.

 Specific Aim 2: To use a saccadic eye movement task to assess saccadic eye movement vigor in
 response to stable value signals in recently treated PD subjects before and after LDR
 induction.

 Hypothesis 2: LDR induction will result in partial restoration of saccadic eye movement vigor
 in response to previously learned stable value signals in PD subjects in the "practical off"
 state.

 Validation of our hypotheses would have considerable impact by identifying a specific
 functional process underlying the LDR and a potential mechanism of the LDR. This will
 facilitate research into LDR mechanisms, provide a rational basis for developing valid animal
 models of the LDR, and open a new path towards improved symptomatic management of PD.
Inclusion Criteria:

 -  Diagnosis of Parkinson Disease

 -  Previously Untreated or treated for <4 weeks

 -  Mild to Moderate Parkinson disease (Hoehn & Yahr Stages I-II)

 -  About to start treatment with a L-Dopa preparation (Sinemet)

 Exclusion Criteria:

 -  The presence of other neurologic disease or findings on examination

 -  Depression: Geriatric Depression Scale score >11

 -  Use of dopamine agonists or stimulants

 -  Evidence of a stroke or mass lesion on prior structural brain imaging (MRI or CT)

 -  Evidence of any confounding medical or psychiatric problem that would preclude task
 participation.

 -  Participants with cognitive impairment that might impair their capacity to provide
 informed consent.