Clinical trial NCT03042962: Brain Networks in Dystonia
Official title: Brain Networks in Dystonia
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Spasmodic Dysphonia
Singer's Dystonia
Writer's Cramp
Musician's Focal Hand Dystonia
Keywords: dystonia
imaging
genetics
neuropathology
Lead sponsor: Massachusetts Eye and Ear Infirmary
Sponsor class: OTHER
Collaborators: name: National Institute of Neurological Disorders and Stroke (NINDS)
First posted: 2017-02-03
Enrollment: 141
Sex: ALL
Minimum age (years): 21
Maximum age (years): 80
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Observational model: COHORT
Time perspective: CROSS_SECTIONAL
Sampling method: NON_PROBABILITY_SAMPLE
Study population: Patients with writer's cramp, musician's focal hand dystonia, spasmodic dysphonia, singer's dystonia, and healthy volunteers

Brief summary: Task-specific focal dystonias are characterized by selective activation of dystonic movements during performance of highly learned motor tasks, such as writing or playing a musical instrument. To date, there is only limited knowledge about the distinct neural abnormalities that lead to the development of task-specificity in focal dystonias, which affect similar muscle groups but result in different clinical manifestations, such as writer's cramp vs. pianist's dystonia or spasmodic dysphonia vs. singer's dystonia. Our goal is to dissect the pathophysiological mechanisms underlying the phenomenon of task specificity in isolated focal dystonias using multi-level brain network analysis in conjunction with neuropathological examination of postmortem brain tissue from patients with dystonia. Rather than viewing these disorders as interesting curiosities, understanding the biology of task-specific activation of motor programs is central to understanding dystonia.

Detailed description: Task-specific primary focal dystonias (tsPFDs) are characterized by selective activation of dystonic movements during performance of highly learned motor tasks, such as writing, playing a musical instrument, speaking, or singing. Despite the recent advances in describing the clinical features of dystonia, there is a fundamental gap in understanding the neural abnormalities underlying the development of tsPFDs, which affect the same muscles but result in different clinical manifestations as in writer's cramp vs. pianist's dystonia or spasmodic dysphonia vs. singer's dystonia. Continued existence of this gap is an important problem because it renders us unable to differentiate between primary and secondary brain changes contributing to the tsPFD pathophysiology and to develop novel treatment options targeting disorder-specific brain alterations. The objective of this application is to identify the brain mechanisms underlying the phenomenon of task specificity in two representative groups of patients with writer's cramp vs. musician's hand dystonia and spasmodic dysphonia vs. singer's laryngeal dystonia using a novel approach of combined clinico-behavioral examination, brain network analysis and quantitative neuropathology of postmortem brain tissue. Our central hypothesis is that each tsPFD is characterized by distinct brain abnormalities, which selectively affect the focal segments of brain networks responsible for the performance of the respective motor task. The rationale for the proposed research is that identification of tsPFD-specific brain changes and associated neuropathology will clarify the neural mechanisms (primary vs. secondary) contributing to the clinical manifestation of these disorders and thus explain the phenomenon of tsPFDs. The obtained results are expected to provide strong scientific bases for the next series of studies directed towards identification and validation of novel pharmacological and/or surgical therapies for these patients. The researchers will pursue the following two specific aims: (1) determine distinct features of brain functional network abnormalities underlying task-specificity in different tsPFDs, and (2) establish structural correlates of functional neuroimaging abnormalities in tsPFDs. The proposed research is significant because it is expected to establish scientific evidence that tsPFD is a network disorder with abnormalities following distinct patterns in different tsPFDs and certain abnormalities showing structure-function correlations are associated with underlying neuropathology. By converging the results from multimodal cross-disciplinary studies to a coherent and pathophysiologically meaningful picture, the researchers will be well positioned to identify primary vs. secondary changes in tsPFDs and establish a scientific framework for the development of diagnostic biomarkers and novel treatment options for these disorders.

Eligibility criteria: Inclusion Criteria:

* Patients will have clinically documented focal dystonia (including spasmodic dysphonia, singer's dystonia, writer's cramp, musician's focal hand dystonia)
* Healthy controls will be healthy volunteers with a negative history of neurological, laryngeal or psychiatric problems
* Age from 21 to 80 years.
* Native English speakers.
* Right-handedness (based on Edinburgh Handedness Inventory).

Exclusion Criteria:

* Subjects who are incapable of giving an informed consent.
* Pregnant or breastfeeding women until a time when they are no longer pregnant or breastfeeding. All women of childbearing potential will have a urine pregnancy test performed, which must be negative for participation in the imaging studies.
* Subjects with past or present medical history of (a) neurological problems, such as stroke, movement disorders (other than dystonia in the patient groups), brain tumors, traumatic brain injury with loss of consciousness, ataxias, myopathies, myasthenia gravis, demyelinating diseases, alcoholism, drug depend-ence; (b) psychiatric problems, such as schizophrenia, major and/or bipolar depression, obsessive-compulsive disorder; (c) laryngeal problems, such as vocal fold paralysis, paresis, vocal fold nodules and polyps, carcinoma, chronic laryngitis.
* Patients who are not symptomatic due to treatment with botulinum toxin injections into the laryngeal muscles. The duration of positive effects of botulinum toxin vary from patient to patient but lasts on average for 3-4 months. All patients will be evaluated to ensure that they are fully symptomatic prior to entering the study.
* Patients with other forms of dystonia.
* Patients with hereditary forms of dystonia (e.g., DYT1, DYT6, GNAL). If ARSG gene is identified in musician's dystonia patients, it will be used as a nuisance covariate in imaging analysis.
* Patients who have dystonia symptoms at rest in order to avoid the potential confound of dystonic spasms occurring during the scanning.
* To avoid the possibility of confounding effects of drugs acting upon the central nervous system, all study participants will be questioned about any prescribed or over-the-counter medications as part of their initial intake screening. Those patients who receive medication(s) affecting the central nervous system will be excluded from the study.
* The patients will be asked whether they have undergone any head, neck, or hand surgeries, which resulted in changes in regional anatomy or innervation. Because brain, hand and laryngeal surgery may potentially lead to the brain structure and function re-organization, all patients with history of brain, hand and/or laryngeal surgery will be excluded from the study.
* Subjects who have tattoos, ferromagnetic objects in their bodies (e.g., implanted stimulators, surgical clips, prosthesis, artificial heart valve, etc.) that cannot be removed for the purpose of study participation.

Primary outcomes:
measure: Incidence of brain structural and functional changes
timeFrame: 5 years
Secondary outcomes:
Other outcomes:
Locations:
city: Boston
country: United States
facility: Massachusetts Eye and Ear Infirmary
state: Massachusetts
Study officials:
affiliation: Massachusetts Eye and Ear Infirmary
name: Kristina Simonyan, MD, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Battistella G, Termsarasab P, Ramdhani RA, Fuertinger S, Simonyan K. Isolated Focal Dystonia as a Disorder of Large-Scale Functional Networks. Cereb Cortex. 2017 Feb 1;27(2):1203-1215. doi: 10.1093/cercor/bhv313.
citation: Fuertinger S, Simonyan K. Stability of Network Communities as a Function of Task Complexity. J Cogn Neurosci. 2016 Dec;28(12):2030-2043. doi: 10.1162/jocn_a_01026. Epub 2016 Aug 30.
citation: Rittiner JE, Caffall ZF, Hernandez-Martinez R, Sanderson SM, Pearson JL, Tsukayama KK, Liu AY, Xiao C, Tracy S, Shipman MK, Hickey P, Johnson J, Scott B, Stacy M, Saunders-Pullman R, Bressman S, Simonyan K, Sharma N, Ozelius LJ, Cirulli ET, Calakos N. Functional Genomic Analyses of Mendelian and Sporadic Disease Identify Impaired eIF2alpha Signaling as a Generalizable Mechanism for Dystonia. Neuron. 2016 Dec 21;92(6):1238-1251. doi: 10.1016/j.neuron.2016.11.012. Epub 2016 Dec 8.
citation: Fuertinger S, Simonyan K. Connectome-Wide Phenotypical and Genotypical Associations in Focal Dystonia. J Neurosci. 2017 Aug 2;37(31):7438-7449. doi: 10.1523/JNEUROSCI.0384-17.2017. Epub 2017 Jul 3.
citation: Simonyan K, Barkmeier-Kraemer J, Blitzer A, Hallett M, Houde JF, Jacobson Kimberley T, Ozelius LJ, Pitman MJ, Richardson RM, Sharma N, Tanner K; The NIH/NIDCD Workshop on Research Priorities in Spasmodic Dysphonia/Laryngeal Dystonia. Laryngeal Dystonia: Multidisciplinary Update on Terminology, Pathophysiology, and Research Priorities. Neurology. 2021 May 25;96(21):989-1001. doi: 10.1212/WNL.0000000000011922. Epub 2021 Apr 15.
citation: Worthley A, Simonyan K. Suicidal Ideations and Attempts in Patients With Isolated Dystonia. Neurology. 2021 Mar 16;96(11):e1551-e1560. doi: 10.1212/WNL.0000000000011596. Epub 2021 Jan 27.
citation: Valeriani D, Simonyan K. A microstructural neural network biomarker for dystonia diagnosis identified by a DystoniaNet deep learning platform. Proc Natl Acad Sci U S A. 2020 Oct 20;117(42):26398-26405. doi: 10.1073/pnas.2009165117. Epub 2020 Oct 1.
citation: Hanekamp S, Simonyan K. The large-scale structural connectome of task-specific focal dystonia. Hum Brain Mapp. 2020 Aug 15;41(12):3253-3265. doi: 10.1002/hbm.25012. Epub 2020 Apr 20.
citation: Maguire F, Reilly RB, Simonyan K. Normal Temporal Discrimination in Musician's Dystonia Is Linked to Aberrant Sensorimotor Processing. Mov Disord. 2020 May;35(5):800-807. doi: 10.1002/mds.27984. Epub 2020 Jan 13.
citation: Lungu C, Ozelius L, Standaert D, Hallett M, Sieber BA, Swanson-Fisher C, Berman BD, Calakos N, Moore JC, Perlmutter JS, Pirio Richardson SE, Saunders-Pullman R, Scheinfeldt L, Sharma N, Sillitoe R, Simonyan K, Starr PA, Taylor A, Vitek J; participants and organizers of the NINDS Workshop on Research Priorities in Dystonia. Defining research priorities in dystonia. Neurology. 2020 Mar 24;94(12):526-537. doi: 10.1212/WNL.0000000000009140. Epub 2020 Feb 25.
citation: Guiry S, Worthley A, Simonyan K. A separation of innate and learned vocal behaviors defines the symptomatology of spasmodic dysphonia. Laryngoscope. 2019 Jul;129(7):1627-1633. doi: 10.1002/lary.27617. Epub 2018 Dec 24.
citation: Bianchi S, Fuertinger S, Huddleston H, Frucht SJ, Simonyan K. Functional and structural neural bases of task specificity in isolated focal dystonia. Mov Disord. 2019 Apr;34(4):555-563. doi: 10.1002/mds.27649. Epub 2019 Mar 6.
citation: Simonyan K. Recent advances in understanding the role of the basal ganglia. F1000Res. 2019 Jan 30;8:F1000 Faculty Rev-122. doi: 10.12688/f1000research.16524.1. eCollection 2019.
citation: Fuertinger S, Simonyan K. Task-specificity in focal dystonia is shaped by aberrant diversity of a functional network kernel. Mov Disord. 2018 Dec;33(12):1918-1927. doi: 10.1002/mds.97. Epub 2018 Sep 27.
citation: Simonyan K. Neuroimaging Applications in Dystonia. Int Rev Neurobiol. 2018;143:1-30. doi: 10.1016/bs.irn.2018.09.007. Epub 2018 Oct 23.
citation: Blitzer A, Brin MF, Simonyan K, Ozelius LJ, Frucht SJ. Phenomenology, genetics, and CNS network abnormalities in laryngeal dystonia: A 30-year experience. Laryngoscope. 2018 Jan;128 Suppl 1(Suppl 1):S1-S9. doi: 10.1002/lary.27003. Epub 2017 Dec 8.
citation: Mor N, Simonyan K, Blitzer A. Central voice production and pathophysiology of spasmodic dysphonia. Laryngoscope. 2018 Jan;128(1):177-183. doi: 10.1002/lary.26655. Epub 2017 May 23.
citation: Killian O, McGovern EM, Beck R, Beiser I, Narasimham S, Quinlivan B, O'Riordan S, Simonyan K, Hutchinson M, Reilly RB. Practice does not make perfect: Temporal discrimination in musicians with and without dystonia. Mov Disord. 2017 Dec;32(12):1791-1792. doi: 10.1002/mds.27185. Epub 2017 Oct 27. No abstract available.
citation: Simonyan K, Ackermann H, Chang EF, Greenlee JD. New Developments in Understanding the Complexity of Human Speech Production. J Neurosci. 2016 Nov 9;36(45):11440-11448. doi: 10.1523/JNEUROSCI.2424-16.2016.
citation: Laabs BH, Lohmann K, Vollstedt EJ, Reinberger T, Nuxoll LM, Kilic-Berkmen G, Perlmutter JS, Loens S, Cruchaga C, Franke A, Dobricic V, Hinrichs F, Grozinger A, Altenmuller E, Bellows S, Boesch S, Bressman SB, Duque KR, Espay AJ, Ferbert A, Feuerstein JS, Frank S, Gasser T, Haslinger B, Jech R, Kaiser F, Kamm C, Kollewe K, Kuhn AA, LeDoux MS, Lohmann E, Mahajan A, Munchau A, Multhaupt-Buell T, Pantelyat A, Pirio Richardson SE, Raymond D, Reich SG, Saunders Pullman R, Schormair B, Sharma N, Sichani AH, Simonyan K, Volkmann J, Wagle Shukla A, Winkelmann J, Wright LJ, Zech M, Zeuner KE, Zittel S, Kasten M, Sun YV, Baumer T, Bruggemann N, Ozelius LJ, Jinnah HA, Klein C, Konig IR. Genetic Risk Factors in Isolated Dystonia Escape Genome-Wide Association Studies. Mov Disord. 2024 Nov;39(11):2110-2116. doi: 10.1002/mds.29968. Epub 2024 Sep 17.
citation: Schill J, Simonyan K, Corsten M, Mathys C, Thiel C, Witt K. Graph-theoretical insights into the effects of aging on the speech production network. Cereb Cortex. 2023 Feb 20;33(5):2162-2173. doi: 10.1093/cercor/bhac198.
citation: Schill J, Zeuner KE, Knutzen A, Todt I, Simonyan K, Witt K. Functional Neural Networks in Writer's Cramp as Determined by Graph-Theoretical Analysis. Front Neurol. 2021 Nov 23;12:744503. doi: 10.3389/fneur.2021.744503. eCollection 2021.
citation: Yao D, O'Flynn LC, Simonyan K. DystoniaBoTXNet: Novel Neural Network Biomarker of Botulinum Toxin Efficacy in Isolated Dystonia. Ann Neurol. 2023 Mar;93(3):460-471. doi: 10.1002/ana.26558. Epub 2022 Dec 14.
citation: Frankford SA, O'Flynn LC, Simonyan K. Sensory processing in the auditory and olfactory domains is normal in laryngeal dystonia. J Neurol. 2023 Apr;270(4):2184-2190. doi: 10.1007/s00415-023-11562-z. Epub 2023 Jan 14.
citation: Battistella G, Simonyan K. Clinical Implications of Dystonia as a Neural Network Disorder. Adv Neurobiol. 2023;31:223-240. doi: 10.1007/978-3-031-26220-3_13. Epub 2023 Jun 21.
citation: Schill J, Simonyan K, Lang S, Mathys C, Thiel C, Witt K. Parkinson's disease speech production network as determined by graph-theoretical network analysis. Netw Neurosci. 2023 Jun 30;7(2):712-730. doi: 10.1162/netn_a_00310. eCollection 2023.