La maladie de Parkinson au Canada (serveur d'exploration)

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Asymmetrical Effect of Levodopa on the Neural Activity of Motor Regions in PD

Identifieur interne : 000092 ( Pmc/Corpus ); précédent : 000091; suivant : 000093

Asymmetrical Effect of Levodopa on the Neural Activity of Motor Regions in PD

Auteurs : Kristina Martinu ; Atsuko Nagano-Saito ; Stuart Fogel ; Oury Monchi

Source :

RBID : PMC:4219727

Abstract

Parkinson's disease (PD) is a neurodegenerative illness often characterized by asymmetrical symptoms. However, the reason for this asymmetry and the cerebral correlates underlying symptom asymmetry are still not well understood. Furthermore, the effects of levodopa on the cerebral correlates of disease asymmetry have not been investigated. In this study, right-handed PD patients performed self-initiated, externally triggered and repetitive control finger movements with both their right and left hands during functional magnetic resonance imaging (fMRI) to investigate asymmetrical effects of levodopa on the hemodynamic correlates of finger movements. Patients completed two experimental sessions OFF and ON medication after a minimum of 12 hours medication withdrawal. We compared the effect of levodopa on the neural activation patterns underlying the execution of both the more affected and less affected hand for self-initiated and externally triggered movements. Our results show that levodopa led to larger differences in cerebral activity for movements of the more affected, left side: there were significant differences in activity after levodopa administration in regions of the motor cortico-striatal network when patients performed self-initiated and externally triggered movements with their left hand. By contrast, when patients used their right hand, levodopa led to differences in cerebellar activity only. As our patients were affected more severely on their left side, we propose that levodopa may help provide additional dopaminergic input, improving movements for the more severely affected side. These results suggest that the impact of reduced dopamine in the cortico-striatal system and the action of levodopa is not symmetrical.


Url:
DOI: 10.1371/journal.pone.0111600
PubMed: 25369523
PubMed Central: 4219727

Links to Exploration step

PMC:4219727

Le document en format XML

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<p>Parkinson's disease (PD) is a neurodegenerative illness often characterized by asymmetrical symptoms. However, the reason for this asymmetry and the cerebral correlates underlying symptom asymmetry are still not well understood. Furthermore, the effects of levodopa on the cerebral correlates of disease asymmetry have not been investigated. In this study, right-handed PD patients performed self-initiated, externally triggered and repetitive control finger movements with both their right and left hands during functional magnetic resonance imaging (fMRI) to investigate asymmetrical effects of levodopa on the hemodynamic correlates of finger movements. Patients completed two experimental sessions OFF and ON medication after a minimum of 12 hours medication withdrawal. We compared the effect of levodopa on the neural activation patterns underlying the execution of both the more affected and less affected hand for self-initiated and externally triggered movements. Our results show that levodopa led to larger differences in cerebral activity for movements of the more affected, left side: there were significant differences in activity after levodopa administration in regions of the motor cortico-striatal network when patients performed self-initiated and externally triggered movements with their left hand. By contrast, when patients used their right hand, levodopa led to differences in cerebellar activity only. As our patients were affected more severely on their left side, we propose that levodopa may help provide additional dopaminergic input, improving movements for the more severely affected side. These results suggest that the impact of reduced dopamine in the cortico-striatal system and the action of levodopa is not symmetrical.</p>
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<name sortKey="Rodriguez, M" uniqKey="Rodriguez M">M Rodriguez</name>
</author>
<author>
<name sortKey="Lera, G" uniqKey="Lera G">G Lera</name>
</author>
<author>
<name sortKey="Vaamonde, J" uniqKey="Vaamonde J">J Vaamonde</name>
</author>
<author>
<name sortKey="Luquin, Mr" uniqKey="Luquin M">MR Luquin</name>
</author>
<author>
<name sortKey="Obeso, Ja" uniqKey="Obeso J">JA Obeso</name>
</author>
</analytic>
</biblStruct>
<biblStruct>
<analytic>
<author>
<name sortKey="Kumar, A" uniqKey="Kumar A">A Kumar</name>
</author>
<author>
<name sortKey="Mann, S" uniqKey="Mann S">S Mann</name>
</author>
<author>
<name sortKey="Sossi, V" uniqKey="Sossi V">V Sossi</name>
</author>
<author>
<name sortKey="Ruth, Tj" uniqKey="Ruth T">TJ Ruth</name>
</author>
<author>
<name sortKey="Stoessl, Aj" uniqKey="Stoessl A">AJ Stoessl</name>
</author>
</analytic>
</biblStruct>
</listBibl>
</div1>
</back>
</TEI>
<pmc article-type="research-article">
<pmc-dir>properties open_access</pmc-dir>
<front>
<journal-meta>
<journal-id journal-id-type="nlm-ta">PLoS One</journal-id>
<journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id>
<journal-id journal-id-type="publisher-id">plos</journal-id>
<journal-id journal-id-type="pmc">plosone</journal-id>
<journal-title-group>
<journal-title>PLoS ONE</journal-title>
</journal-title-group>
<issn pub-type="epub">1932-6203</issn>
<publisher>
<publisher-name>Public Library of Science</publisher-name>
<publisher-loc>San Francisco, USA</publisher-loc>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="pmid">25369523</article-id>
<article-id pub-id-type="pmc">4219727</article-id>
<article-id pub-id-type="publisher-id">PONE-D-14-18118</article-id>
<article-id pub-id-type="doi">10.1371/journal.pone.0111600</article-id>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Research Article</subject>
</subj-group>
<subj-group subj-group-type="Discipline-v2">
<subject>Biology and Life Sciences</subject>
<subj-group>
<subject>Anatomy</subject>
<subj-group>
<subject>Nervous System</subject>
<subj-group>
<subject>Motor System</subject>
</subj-group>
</subj-group>
</subj-group>
<subj-group>
<subject>Biochemistry</subject>
<subj-group>
<subject>Neurochemistry</subject>
<subj-group>
<subject>Neurochemicals</subject>
<subj-group>
<subject>Levodopa</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group>
<subject>Neuroscience</subject>
<subj-group>
<subject>Brain Mapping</subject>
<subj-group>
<subject>Functional Magnetic Resonance Imaging</subject>
</subj-group>
</subj-group>
<subj-group>
<subject>Cognitive Neuroscience</subject>
<subject>Cognitive Science</subject>
<subject>Neuroimaging</subject>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v2">
<subject>Medicine and Health Sciences</subject>
<subj-group>
<subject>Neurology</subject>
<subj-group>
<subject>Neurodegenerative Diseases</subject>
<subj-group>
<subject>Movement Disorders</subject>
<subj-group>
<subject>Parkinson Disease</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group>
<subject>Pharmacology</subject>
<subj-group>
<subject>Drugs</subject>
</subj-group>
</subj-group>
</subj-group>
</article-categories>
<title-group>
<article-title>Asymmetrical Effect of Levodopa on the Neural Activity of Motor Regions in PD</article-title>
<alt-title alt-title-type="running-head">Levodopa and Disease Asymmetry in PD</alt-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname>Martinu</surname>
<given-names>Kristina</given-names>
</name>
<xref ref-type="aff" rid="aff1">
<sup>1</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Nagano-Saito</surname>
<given-names>Atsuko</given-names>
</name>
<xref ref-type="aff" rid="aff1">
<sup>1</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Fogel</surname>
<given-names>Stuart</given-names>
</name>
<xref ref-type="aff" rid="aff1">
<sup>1</sup>
</xref>
<xref ref-type="aff" rid="aff2">
<sup>2</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Monchi</surname>
<given-names>Oury</given-names>
</name>
<xref ref-type="aff" rid="aff1">
<sup>1</sup>
</xref>
<xref ref-type="aff" rid="aff3">
<sup>3</sup>
</xref>
<xref ref-type="corresp" rid="cor1">
<sup>*</sup>
</xref>
</contrib>
</contrib-group>
<aff id="aff1">
<label>1</label>
<addr-line>Centre de Recherche de l′Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada</addr-line>
</aff>
<aff id="aff2">
<label>2</label>
<addr-line>Brain & Mind Institute, Department of Psychology, Western University, London, Ontario, Canada</addr-line>
</aff>
<aff id="aff3">
<label>3</label>
<addr-line>Department of Radiology, Université de Montréal, Montreal, Quebec, Canada</addr-line>
</aff>
<contrib-group>
<contrib contrib-type="editor">
<name>
<surname>Sgambato-Faure</surname>
<given-names>Véronique</given-names>
</name>
<role>Editor</role>
<xref ref-type="aff" rid="edit1"></xref>
</contrib>
</contrib-group>
<aff id="edit1">
<addr-line>INSERM/CNRS, France</addr-line>
</aff>
<author-notes>
<corresp id="cor1">* E-mail:
<email>oury.monchi@umontreal.ca</email>
</corresp>
<fn fn-type="conflict">
<p>
<bold>Competing Interests: </bold>
The authors have declared that no competing interests exist.</p>
</fn>
<fn fn-type="con">
<p>Conceived and designed the experiments: OM KM. Performed the experiments: KM. Analyzed the data: KM ANS SF. Wrote the paper: KM SF.</p>
</fn>
</author-notes>
<pub-date pub-type="collection">
<year>2014</year>
</pub-date>
<pub-date pub-type="epub">
<day>4</day>
<month>11</month>
<year>2014</year>
</pub-date>
<volume>9</volume>
<issue>11</issue>
<elocation-id>e111600</elocation-id>
<history>
<date date-type="received">
<day>6</day>
<month>5</month>
<year>2014</year>
</date>
<date date-type="accepted">
<day>3</day>
<month>9</month>
<year>2014</year>
</date>
</history>
<permissions>
<copyright-year>2014</copyright-year>
<copyright-holder>Martinu et al</copyright-holder>
<license>
<license-p>This is an open-access article distributed under the terms of the
<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>
, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p>
</license>
</permissions>
<abstract>
<p>Parkinson's disease (PD) is a neurodegenerative illness often characterized by asymmetrical symptoms. However, the reason for this asymmetry and the cerebral correlates underlying symptom asymmetry are still not well understood. Furthermore, the effects of levodopa on the cerebral correlates of disease asymmetry have not been investigated. In this study, right-handed PD patients performed self-initiated, externally triggered and repetitive control finger movements with both their right and left hands during functional magnetic resonance imaging (fMRI) to investigate asymmetrical effects of levodopa on the hemodynamic correlates of finger movements. Patients completed two experimental sessions OFF and ON medication after a minimum of 12 hours medication withdrawal. We compared the effect of levodopa on the neural activation patterns underlying the execution of both the more affected and less affected hand for self-initiated and externally triggered movements. Our results show that levodopa led to larger differences in cerebral activity for movements of the more affected, left side: there were significant differences in activity after levodopa administration in regions of the motor cortico-striatal network when patients performed self-initiated and externally triggered movements with their left hand. By contrast, when patients used their right hand, levodopa led to differences in cerebellar activity only. As our patients were affected more severely on their left side, we propose that levodopa may help provide additional dopaminergic input, improving movements for the more severely affected side. These results suggest that the impact of reduced dopamine in the cortico-striatal system and the action of levodopa is not symmetrical.</p>
</abstract>
<funding-group>
<funding-statement>This study was supported by an operating grant (MOP-81114) from the Canadian Institutes of Health Research to OM. KM received a PhD fellowship from the Parkinson Society Canada. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement>
</funding-group>
<counts>
<page-count count="8"></page-count>
</counts>
<custom-meta-group>
<custom-meta id="data-availability">
<meta-name>Data Availability</meta-name>
<meta-value>The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. Raw data can be downloaded from the Centre de recherche, Institut universitaire de geriatrie de Montreal:
<ext-link ext-link-type="uri" xlink:href="http://downloads.criugm.qc.ca/pub/Martinu_2014_PlosOne.tar.gz">http://downloads.criugm.qc.ca/pub/Martinu_2014_PlosOne.tar.gz</ext-link>
.</meta-value>
</custom-meta>
</custom-meta-group>
</article-meta>
<notes>
<title>Data Availability</title>
<p>The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. Raw data can be downloaded from the Centre de recherche, Institut universitaire de geriatrie de Montreal:
<ext-link ext-link-type="uri" xlink:href="http://downloads.criugm.qc.ca/pub/Martinu_2014_PlosOne.tar.gz">http://downloads.criugm.qc.ca/pub/Martinu_2014_PlosOne.tar.gz</ext-link>
.</p>
</notes>
</front>
<body>
<sec id="s1">
<title>Introduction</title>
<p>Parkinson's disease (PD) is a neurodegenerative disease whose cardinal symptoms are rigidity, tremor and bradykinesia. Symptoms often manifest more severely on one side of the body, and this lateralization persists throughout the duration of the disease
<xref rid="pone.0111600-Djaldetti1" ref-type="bibr">[1]</xref>
,
<xref rid="pone.0111600-Hoehn1" ref-type="bibr">[2]</xref>
. The underlying physiological and functional cerebral substrates of disease asymmetry in PD and their interaction with levodopa are poorly understood. Here we used self-initiated (SI) and externally-triggered (ET) movements during fMRI to investigate the effect of levodopa on the neural patterns underlying movements of asymmetrically affected hands.</p>
<p>The involvement of cortical regions and the basal ganglia in movement has long been documented
<xref rid="pone.0111600-Deecke1" ref-type="bibr">[3]</xref>
<xref rid="pone.0111600-Schultz1" ref-type="bibr">[6]</xref>
. For right handed individuals, movements of the left hand lead to greater increases in activity in motor areas than right hand movements
<xref rid="pone.0111600-Mattay1" ref-type="bibr">[7]</xref>
, and cortical, subcortical and cerebellar task-related activity has been shown to decrease with automaticity
<xref rid="pone.0111600-Wu1" ref-type="bibr">[8]</xref>
. Although patients with PD can also reach movement automaticity, they show greater increases in cortical and cerebellar activity than healthy controls when doing so
<xref rid="pone.0111600-Wu2" ref-type="bibr">[9]</xref>
. We have previously shown that regions implicated in the motor cortico-striatal circuit (putamen, thalamus and premotor cortex) are involved in both SI and ET movements
<xref rid="pone.0111600-FrancoisBrosseau1" ref-type="bibr">[10]</xref>
,
<xref rid="pone.0111600-Martinu1" ref-type="bibr">[11]</xref>
. More specifically, in young healthy adults, we have shown that activity of the putamen increases during repetitive control, ET and SI movements performed with the right hand. When using the left hand, however, activity of the putamen plateaued for both ET and SI movements. We suggested that the gradual involvement of the putamen during right hand movements is masked by the lack of proficiency of the non-dominant hand
<xref rid="pone.0111600-FrancoisBrosseau1" ref-type="bibr">[10]</xref>
. However, it remains to be investigated whether symptom asymmetry may impact task-related cerebral activation, and the response in the affected regions to dopamine therapy.</p>
<p>When dopamine levels are deficient, such as in PD, dopamine replacement therapy such as levodopa and apomorphine can restore motor-related activity
<xref rid="pone.0111600-Feigin1" ref-type="bibr">[12]</xref>
<xref rid="pone.0111600-Jenkins2" ref-type="bibr">[14]</xref>
. We have previously shown that the effect of levodopa in PD leads to an increase in activity in the putamen whether movements are SI or ET
<xref rid="pone.0111600-Martinu1" ref-type="bibr">[11]</xref>
. We did not, however, investigate the differences in the effect of levodopa on the neural patterns linked to asymmetrically affected hands.</p>
<p>The goal of the present study was to examine the effect of levodopa on the neural activation patterns underlying asymmetrically affected left and right hand movements. We hypothesized that levodopa may lead to an increase in activity in the motor cortico-striatal network during more affected-side hand movements. Consistent with our previous work, we further hypothesized that this effect would be equivalent for both SI and ET movements (i.e., not task-specific). In our group of right-handed patients, we selected patients with more pronounced symptoms on the non-dominant side. We hypothesized that levodopa might selectively act on movements of the left hand, perhaps compensating for symptom severity. Understanding the interaction between levodopa and disease asymmetry would allow for new perspectives on levodopa mechanisms and subsequent research, and treatment of, asymmetrical symptoms.</p>
</sec>
<sec sec-type="methods" id="s2">
<title>Methods</title>
<sec id="s2a">
<title>Participants</title>
<p>Eleven right-handed patients diagnosed with PD [mean age 62.36±6.70 (SD), 6 men] and with higher symptom severity on the left side participated (
<xref ref-type="table" rid="pone-0111600-t001">Table 1</xref>
). All PD participants met the UK brain bank criteria
<xref rid="pone.0111600-Hughes1" ref-type="bibr">[15]</xref>
for the diagnosis of idiopathic PD. Motor disability of patients with PD was mild to moderate severity, according to the Hoehn and Yahr staging criteria
<xref rid="pone.0111600-Hoehn1" ref-type="bibr">[2]</xref>
. Patients presenting any other neurological or psychiatric disorder were excluded. Handedness was assessed with the Edinburgh Handedness Inventory (mean 90.8±14.9), early signs of dementia were assessed using the Montreal Cognitive Assessment (MoCA)
<xref rid="pone.0111600-Nasreddine1" ref-type="bibr">[16]</xref>
(mean OFF 27.2±1.7, ON 27.2±1.5), and symptoms of depression in all participants were measured using the Beck Depression Inventory II (BDI-II) (mean 9.9±7.5). At each session, motor symptoms were measured with the unified Parkinson's disease rating scale (UPDRS-III) (OFF: 31.55±4.9 and ON: 22.95±5.8). Left and right subsections were separated to give left and right UPDRS scores (OFF: 11.5L/9.5R and ON: 9.4L/6.6R). In addition to levodopa, some patients also regularly took other anti-parkinsonian drugs such as COMT inhibitors (n = 4), MAO-B inhibitors (n = 6), dopamine agonists (n = 3) and others (n = 3). Patients remained off these other medications for both the ON and OFF sessions.</p>
<table-wrap id="pone-0111600-t001" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0111600.t001</object-id>
<label>Table 1</label>
<caption>
<title>Demographics for the twelve patients with Parkinson's disease.</title>
</caption>
<alternatives>
<graphic id="pone-0111600-t001-1" xlink:href="pone.0111600.t001"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
</colgroup>
<thead>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">MoCA</td>
<td colspan="3" align="left" rowspan="1">UPDRS scores</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Patient</td>
<td align="left" rowspan="1" colspan="1">G</td>
<td align="left" rowspan="1" colspan="1">Age</td>
<td align="left" rowspan="1" colspan="1">Dur.</td>
<td align="left" rowspan="1" colspan="1">Meds</td>
<td align="left" rowspan="1" colspan="1">BDI-II</td>
<td align="left" rowspan="1" colspan="1">Hand.</td>
<td align="left" rowspan="1" colspan="1">(On/Off)</td>
<td align="left" rowspan="1" colspan="1">Total (On/Off)</td>
<td align="left" rowspan="1" colspan="1">Left/Right (On)</td>
<td align="left" rowspan="1" colspan="1">Left/Right (Off)</td>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">1</td>
<td align="left" rowspan="1" colspan="1">F</td>
<td align="left" rowspan="1" colspan="1">69</td>
<td align="left" rowspan="1" colspan="1">2</td>
<td align="left" rowspan="1" colspan="1">1, 2</td>
<td align="left" rowspan="1" colspan="1">0</td>
<td align="left" rowspan="1" colspan="1">100</td>
<td align="left" rowspan="1" colspan="1">27/27</td>
<td align="left" rowspan="1" colspan="1">33.5/39.5</td>
<td align="left" rowspan="1" colspan="1">14/15</td>
<td align="left" rowspan="1" colspan="1">13/15</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">2</td>
<td align="left" rowspan="1" colspan="1">F</td>
<td align="left" rowspan="1" colspan="1">51</td>
<td align="left" rowspan="1" colspan="1">5</td>
<td align="left" rowspan="1" colspan="1">1, 4</td>
<td align="left" rowspan="1" colspan="1">12</td>
<td align="left" rowspan="1" colspan="1">58</td>
<td align="left" rowspan="1" colspan="1">27/27</td>
<td align="left" rowspan="1" colspan="1">18.5/31</td>
<td align="left" rowspan="1" colspan="1">7.5/5</td>
<td align="left" rowspan="1" colspan="1">11.5/7</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">3</td>
<td align="left" rowspan="1" colspan="1">M</td>
<td align="left" rowspan="1" colspan="1">67</td>
<td align="left" rowspan="1" colspan="1">2</td>
<td align="left" rowspan="1" colspan="1">1, 3</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">68.5</td>
<td align="left" rowspan="1" colspan="1">24/27</td>
<td align="left" rowspan="1" colspan="1">26/29</td>
<td align="left" rowspan="1" colspan="1">10/5.5</td>
<td align="left" rowspan="1" colspan="1">10.5/8</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">4</td>
<td align="left" rowspan="1" colspan="1">M</td>
<td align="left" rowspan="1" colspan="1">69</td>
<td align="left" rowspan="1" colspan="1">9</td>
<td align="left" rowspan="1" colspan="1">1, 4, 5</td>
<td align="left" rowspan="1" colspan="1">27</td>
<td align="left" rowspan="1" colspan="1">89</td>
<td align="left" rowspan="1" colspan="1">28/25</td>
<td align="left" rowspan="1" colspan="1">23/34.5</td>
<td align="left" rowspan="1" colspan="1">7/7.5</td>
<td align="left" rowspan="1" colspan="1">11/10.5</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">5</td>
<td align="left" rowspan="1" colspan="1">M</td>
<td align="left" rowspan="1" colspan="1">58</td>
<td align="left" rowspan="1" colspan="1">2</td>
<td align="left" rowspan="1" colspan="1">1, 2, 3</td>
<td align="left" rowspan="1" colspan="1">16</td>
<td align="left" rowspan="1" colspan="1">100</td>
<td align="left" rowspan="1" colspan="1">26/30</td>
<td align="left" rowspan="1" colspan="1">16.5/21.5</td>
<td align="left" rowspan="1" colspan="1">7/3.5</td>
<td align="left" rowspan="1" colspan="1">9/5</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">M</td>
<td align="left" rowspan="1" colspan="1">54</td>
<td align="left" rowspan="1" colspan="1">5</td>
<td align="left" rowspan="1" colspan="1">1, 2, 3, 5</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">83.3</td>
<td align="left" rowspan="1" colspan="1">30/30</td>
<td align="left" rowspan="1" colspan="1">25.5/36</td>
<td align="left" rowspan="1" colspan="1">12/6.5</td>
<td align="left" rowspan="1" colspan="1">16.5/11.5</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">7</td>
<td align="left" rowspan="1" colspan="1">M</td>
<td align="left" rowspan="1" colspan="1">68</td>
<td align="left" rowspan="1" colspan="1">3</td>
<td align="left" rowspan="1" colspan="1">1</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">100</td>
<td align="left" rowspan="1" colspan="1">27/28</td>
<td align="left" rowspan="1" colspan="1">26.5/27.5</td>
<td align="left" rowspan="1" colspan="1">9/8.5</td>
<td align="left" rowspan="1" colspan="1">9/7</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">8</td>
<td align="left" rowspan="1" colspan="1">F</td>
<td align="left" rowspan="1" colspan="1">62</td>
<td align="left" rowspan="1" colspan="1">5</td>
<td align="left" rowspan="1" colspan="1">1, 3, 4</td>
<td align="left" rowspan="1" colspan="1">12</td>
<td align="left" rowspan="1" colspan="1">100</td>
<td align="left" rowspan="1" colspan="1">29/28</td>
<td align="left" rowspan="1" colspan="1">19.5/31.5</td>
<td align="left" rowspan="1" colspan="1">8/5</td>
<td align="left" rowspan="1" colspan="1">14/10.5</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">9</td>
<td align="left" rowspan="1" colspan="1">F</td>
<td align="left" rowspan="1" colspan="1">68</td>
<td align="left" rowspan="1" colspan="1">11</td>
<td align="left" rowspan="1" colspan="1">1, 3, 5</td>
<td align="left" rowspan="1" colspan="1">15</td>
<td align="left" rowspan="1" colspan="1">100</td>
<td align="left" rowspan="1" colspan="1">26/27</td>
<td align="left" rowspan="1" colspan="1">25/31.5</td>
<td align="left" rowspan="1" colspan="1">8/7.5</td>
<td align="left" rowspan="1" colspan="1">9.5/10.5</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">10</td>
<td align="left" rowspan="1" colspan="1">F</td>
<td align="left" rowspan="1" colspan="1">65</td>
<td align="left" rowspan="1" colspan="1">1</td>
<td align="left" rowspan="1" colspan="1">1, 2</td>
<td align="left" rowspan="1" colspan="1">3</td>
<td align="left" rowspan="1" colspan="1">100</td>
<td align="left" rowspan="1" colspan="1">29/26</td>
<td align="left" rowspan="1" colspan="1">26/36</td>
<td align="left" rowspan="1" colspan="1">13/6.5</td>
<td align="left" rowspan="1" colspan="1">13/11</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">11</td>
<td align="left" rowspan="1" colspan="1">M</td>
<td align="left" rowspan="1" colspan="1">55</td>
<td align="left" rowspan="1" colspan="1">2</td>
<td align="left" rowspan="1" colspan="1">1, 3</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">100</td>
<td align="left" rowspan="1" colspan="1">26/28</td>
<td align="left" rowspan="1" colspan="1">12.5/29</td>
<td align="left" rowspan="1" colspan="1">7.5/2</td>
<td align="left" rowspan="1" colspan="1">9.5/8.5</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Average (SD)</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">62.36 (6.7)</td>
<td align="left" rowspan="1" colspan="1">4 (3.2)</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">9.9 (7.5)</td>
<td align="left" rowspan="1" colspan="1">90.8 (14.9)</td>
<td align="left" rowspan="1" colspan="1">27.2/27.5 (1.7/1.5)</td>
<td align="left" rowspan="1" colspan="1">22.95/31.55 (5.8/4.9)</td>
<td align="left" rowspan="1" colspan="1">9.4/6.6 (2.5/3.4)</td>
<td align="left" rowspan="1" colspan="1">11.5/9.5 (2.4/2.7)</td>
</tr>
</tbody>
</table>
</alternatives>
<table-wrap-foot>
<fn id="nt101">
<label></label>
<p>Dur., years since illness onset; Med., parkinsonian medication (1, levodopa; 2, COMT inhibitor; 3, MAO-B inhibitor; 4, dopamine agonist; 5, other); BDI., Hand., Edinburgh Handedness Inventory score.</p>
</fn>
</table-wrap-foot>
</table-wrap>
</sec>
<sec id="s2b">
<title>Ethics consent</title>
<p>All participants provided written informed consent, and the protocol was approved by the Research Ethics Committee of the Regroupement Neuroimagerie Québec, following the guidelines of the Tri-Council Policy Statement of Canada, the Civil Code of Quebec, the Declaration of Helsinki and the code of Nuremberg.</p>
</sec>
<sec id="s2c">
<title>Procedure</title>
<p>All patients came for two counterbalanced scanning sessions (one OFF medication, one ON levodopa), and were asked to withdraw from all anti-parkinsonian medications for a minimum of 12 hours prior to each appointment (see
<xref rid="pone.0111600-Martinu1" ref-type="bibr">[11]</xref>
). Participants remained off medications for the OFF session. For the ON session, participants took their usual dose of levodopa 1 hour prior to the beginning of MRI acquisitions. All participants practiced three blocks of the finger-movement task (for a total of 9 repetitions of each condition) prior to the scanning session to ensure they were comfortable performing it in the scanner.</p>
</sec>
<sec id="s2d">
<title>Task</title>
<p>Participants performed SI, ET and control (CTL) finger movements using left and right hands separately during functional MRI acquisitions in a pseudo-randomised order across runs, in both ON and OFF conditions (previously described in
<xref rid="pone.0111600-Martinu1" ref-type="bibr">[11]</xref>
). Each block began with written instructions, displayed for 2.5s, followed by the appearance of five squares oriented in a horizontal row on the screen, each corresponding to a button on the response box. Participants used all fingers except for the little finger; the square corresponding to the little finger was displayed for hand positioning, but remained inactive. The squares displayed on the screen turned green to indicate when a particular button should be pressed, and turned yellow for the duration of the button press. In the control condition, participants were instructed to repeatedly press a single button chosen at random for the duration of the block. In the ET condition, participants followed a randomly generated sequence. Finally, in the SI condition, participants generated their own sequences of finger movements. Participants were instructed to avoid pressing the same button consecutively in the SI task (this was considered an error), and to refrain from automatic (e.g., 1-2-3-4 or 4-3-2-1) or repeated sequences. For all tasks, participants were instructed to keep a comfortable, regular pace. Task conditions alternated at random after 20 button presses. An incorrect selection resulted in an error, and the corresponding square turned red to provide feedback.</p>
</sec>
<sec id="s2e">
<title>fMRI</title>
<sec id="s2e1">
<title>Data acquisition</title>
<p>Participants were scanned using a 3T Siemens TIM Trio MRI scanner at the Functional Neuroimaging Unit (UNF) of the Centre de Recherche de l′Institut Universitaire de Gériatrie de Montréal (CRIUGM). Each scanning session (ON and OFF) comprised a T1-weighted three-dimensional volume acquisition (voxel size 1 mm
<sup>3</sup>
) for anatomical localization, followed by four T2*-weighted functional echoplanar acquisitions with blood oxygenation level-dependent (BOLD) contrast. Each run consisted of 146 frames of 43 slices (matrix size 128×128, voxel size 2.34×2.34×3 mm) acquired at a repetition time of 3.5 seconds.</p>
</sec>
<sec id="s2e2">
<title>Data analysis</title>
<p>Data analysis was performed using fmristat software and minctools
<xref rid="pone.0111600-Worsley1" ref-type="bibr">[19]</xref>
using a similar analysis strategy to our previous studies
<xref rid="pone.0111600-FrancoisBrosseau1" ref-type="bibr">[10]</xref>
,
<xref rid="pone.0111600-Martinu1" ref-type="bibr">[11]</xref>
, and was based on a linear model with correlated errors. After discarding the first three frames, all images were realigned to the fourth frame for motion correction and smoothed using a 6 mm full width half-maximum (FWHM) isotropic Gaussian kernel. The design matrix of the linear model was first convolved with a difference of two gamma hemodynamic response functions timed to coincide with the acquisition of each slice. The linear model was then re-estimated using least squares to produce estimates of effects and their standard errors. The resulting effect and standard effect images as well as anatomical images were spatially normalized using the ICBM152 atlas
<xref rid="pone.0111600-Collins1" ref-type="bibr">[17]</xref>
,
<xref rid="pone.0111600-Zijdenbos1" ref-type="bibr">[18]</xref>
. In a second step, runs and subjects were analyzed using a mixed-effects linear model. A random-effects analysis was performed by first estimating the ratio of the random-effects variance to the fixed-effects variance, and then regularizing this ratio using spatial smoothing with a Gaussian filter. The amount of smoothing was chosen to achieve 100 effective degrees of freedom
<xref rid="pone.0111600-Worsley2" ref-type="bibr">[20]</xref>
. Within-session analyses (SI vs. CTL, ET vs. CTL, SI vs. ET) were performed by direct comparison using the effects and standard deviation images. Between-session analyses (ON vs. OFF) were performed by direct comparisons using the effects and standard deviation images of all participants in both drug conditions. All peaks at a significance of p<0.001 uncorrected with a cluster size >100 mm
<sup>3</sup>
are reported in result tables.</p>
</sec>
</sec>
</sec>
<sec id="s3">
<title>Results</title>
<sec id="s3a">
<title>Clinical scores</title>
<p>Patients had significantly lower UPDRS scores ON than OFF (p = 0.005). Patients were more affected on the left side, as indicated by the sum of right side versus left side UPDRS scores (
<xref ref-type="table" rid="pone-0111600-t001">Table 1</xref>
). Levodopa did not change the asymmetry of the patients' symptoms. There was no significant effect of session order and no statistical differences between MoCA scores ON and OFF. There were no significant correlations between MoCA or BDI-II scores and behavioral performance during the finger-movement tasks.</p>
</sec>
<sec id="s3b">
<title>Behavioral performance during scanning</title>
<sec id="s3b1">
<title>Reaction times</title>
<p>The mean reaction times for SI, ET and CTL tasks ON and OFF for the left and right hand are reported in
<xref ref-type="table" rid="pone-0111600-t002">Table 2</xref>
. A 3-way repeated measures ANOVA comparing drug condition (ON/OFF), hand (left/right) and task (SI/ET/CTL) revealed a 3-way interaction (p = 0.044). Paired-sample t-tests were used to investigate the effect of medication for the SI, ET and CTR tasks performed with the LH and RH hands. There were no statistical differences between ON and OFF sessions for either task (SI, ET or CTL) when performed with either the left or right hand. Additional paired t-tests were used to investigate the effect of hand used to perform the tasks for either task (SI, ET or CTL) when performed either ON or OFF medication. Surprisingly, patients ON medication had significantly longer reaction times for the left hand compared with the right hand in the CTL task (p = 0.031).</p>
<table-wrap id="pone-0111600-t002" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0111600.t002</object-id>
<label>Table 2</label>
<caption>
<title>Mean reaction time (SD) and percent errors for SI, ET and CTL movements for left and right hand movements of patients OFF and ON medication.</title>
</caption>
<alternatives>
<graphic id="pone-0111600-t002-2" xlink:href="pone.0111600.t002"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
</colgroup>
<thead>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td colspan="3" align="left" rowspan="1">Mean RT (SD) in ms</td>
<td colspan="3" align="left" rowspan="1">Errors (%)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">SI</td>
<td align="left" rowspan="1" colspan="1">ET</td>
<td align="left" rowspan="1" colspan="1">CTL</td>
<td align="left" rowspan="1" colspan="1">SI</td>
<td align="left" rowspan="1" colspan="1">ET</td>
<td align="left" rowspan="1" colspan="1">CTL</td>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">OFF</td>
<td align="left" rowspan="1" colspan="1">LH</td>
<td align="left" rowspan="1" colspan="1">842 (127)</td>
<td align="left" rowspan="1" colspan="1">1110 (231)</td>
<td align="left" rowspan="1" colspan="1">723 (122)</td>
<td align="left" rowspan="1" colspan="1">3.66%</td>
<td align="left" rowspan="1" colspan="1">9.05%</td>
<td align="left" rowspan="1" colspan="1">0.46%</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">RH</td>
<td align="left" rowspan="1" colspan="1">833 (174)</td>
<td align="left" rowspan="1" colspan="1">1108 (318)</td>
<td align="left" rowspan="1" colspan="1">726 (119)</td>
<td align="left" rowspan="1" colspan="1">3.01%</td>
<td align="left" rowspan="1" colspan="1">9.41%</td>
<td align="left" rowspan="1" colspan="1">0.79%</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">ON</td>
<td align="left" rowspan="1" colspan="1">LH</td>
<td align="left" rowspan="1" colspan="1">857 (108)</td>
<td align="left" rowspan="1" colspan="1">1123 (133)</td>
<td align="left" rowspan="1" colspan="1">784 (139)</td>
<td align="left" rowspan="1" colspan="1">2.44%</td>
<td align="left" rowspan="1" colspan="1">7.88%</td>
<td align="left" rowspan="1" colspan="1">1.49%</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">RH</td>
<td align="left" rowspan="1" colspan="1">856 (148)</td>
<td align="left" rowspan="1" colspan="1">1137 (174)</td>
<td align="left" rowspan="1" colspan="1">744 (176)</td>
<td align="left" rowspan="1" colspan="1">2.66%</td>
<td align="left" rowspan="1" colspan="1">10.93%</td>
<td align="left" rowspan="1" colspan="1">1.44%</td>
</tr>
</tbody>
</table>
</alternatives>
</table-wrap>
</sec>
<sec id="s3b2">
<title>Errors</title>
<p>The same analysis strategy was used for errors. The percentages of errors in SI, ET and CTL tasks ON and OFF for the left and right hands are reported in
<xref ref-type="table" rid="pone-0111600-t002">Table 2</xref>
. A 3-way repeated measures ANOVA comparing drug condition, hand and task revealed an effect of task (p = 0.026) with more errors in the ET condition overall, but no effect of drug condition, hand or any significant interactions.</p>
</sec>
</sec>
<sec id="s3c">
<title>fMRI results</title>
<sec id="s3c1">
<title>Self-initiated movements</title>
<p>When comparing patients ON and OFF levodopa administration (ON – OFF) for the SI – CTL contrast (
<xref ref-type="fig" rid="pone-0111600-g001">Figure 1</xref>
,
<xref ref-type="table" rid="pone-0111600-t003">Table 3</xref>
), patients showed significantly increased activity in the right anterior prefrontal cortex (aPFC), left premotor cortex (PMC), bilateral motor cortex, and anterior cingulate cortex in the ON condition when using the left hand. Significant subcortical increases in activity were also observed in the left putamen, right thalamus and right cerebellum. For the right hand, patients ON showed significantly increased activity the right cerebellum only. There were no significant increases in activity in the OFF – ON comparison.</p>
<fig id="pone-0111600-g001" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0111600.g001</object-id>
<label>Figure 1</label>
<caption>
<title>Brain activations for SI – CTL and ET – CTL movements for sessions ON vs. OFF for the more affected (left hand) and less affected (right hand) side.</title>
<p>Anatomical images shown are the average of the T1 acquisitions of all patients transformed into stereotaxic space. The significant peaks are shown for t-stat values between 3 and 6.</p>
</caption>
<graphic xlink:href="pone.0111600.g001"></graphic>
</fig>
<table-wrap id="pone-0111600-t003" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0111600.t003</object-id>
<label>Table 3</label>
<caption>
<title>Activation peaks between patients ON and OFF performing SI compared with CTL movements.</title>
</caption>
<alternatives>
<graphic id="pone-0111600-t003-3" xlink:href="pone.0111600.t003"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
</colgroup>
<thead>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td colspan="5" align="left" rowspan="1">Left hand</td>
<td colspan="5" align="left" rowspan="1">Right hand</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Anatomical area</td>
<td align="left" rowspan="1" colspan="1">BA</td>
<td align="left" rowspan="1" colspan="1">R/L</td>
<td align="left" rowspan="1" colspan="1">x</td>
<td align="left" rowspan="1" colspan="1">y</td>
<td align="left" rowspan="1" colspan="1">z</td>
<td align="left" rowspan="1" colspan="1">t</td>
<td align="left" rowspan="1" colspan="1">cluster</td>
<td align="left" rowspan="1" colspan="1">x</td>
<td align="left" rowspan="1" colspan="1">y</td>
<td align="left" rowspan="1" colspan="1">z</td>
<td align="left" rowspan="1" colspan="1">t</td>
<td align="left" rowspan="1" colspan="1">cluster</td>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">
<bold>ON> OFF</bold>
</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">aPFC</td>
<td align="left" rowspan="1" colspan="1">46/10</td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">44</td>
<td align="left" rowspan="1" colspan="1">48</td>
<td align="left" rowspan="1" colspan="1">18</td>
<td align="left" rowspan="1" colspan="1">3.46</td>
<td align="left" rowspan="1" colspan="1">112</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">PMC</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">L</td>
<td align="left" rowspan="1" colspan="1">−56</td>
<td align="left" rowspan="1" colspan="1">2</td>
<td align="left" rowspan="1" colspan="1">40</td>
<td align="left" rowspan="1" colspan="1">3.99</td>
<td align="left" rowspan="1" colspan="1">584</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Motor</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">L</td>
<td align="left" rowspan="1" colspan="1">−28</td>
<td align="left" rowspan="1" colspan="1">−18</td>
<td align="left" rowspan="1" colspan="1">54</td>
<td align="left" rowspan="1" colspan="1">3.75</td>
<td align="left" rowspan="1" colspan="1">168</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">24</td>
<td align="left" rowspan="1" colspan="1">−18</td>
<td align="left" rowspan="1" colspan="1">54</td>
<td align="left" rowspan="1" colspan="1">3.86</td>
<td align="left" rowspan="1" colspan="1">248</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">24</td>
<td align="left" rowspan="1" colspan="1">−14</td>
<td align="left" rowspan="1" colspan="1">72</td>
<td align="left" rowspan="1" colspan="1">3.42</td>
<td align="left" rowspan="1" colspan="1">112</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Cingulate</td>
<td align="left" rowspan="1" colspan="1">32</td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">16</td>
<td align="left" rowspan="1" colspan="1">12</td>
<td align="left" rowspan="1" colspan="1">36</td>
<td align="left" rowspan="1" colspan="1">3.88</td>
<td align="left" rowspan="1" colspan="1">168</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Putamen</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">L</td>
<td align="left" rowspan="1" colspan="1">−26</td>
<td align="left" rowspan="1" colspan="1">−12</td>
<td align="left" rowspan="1" colspan="1">18</td>
<td align="left" rowspan="1" colspan="1">3.52</td>
<td align="left" rowspan="1" colspan="1">600</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">−28</td>
<td align="left" rowspan="1" colspan="1">−18</td>
<td align="left" rowspan="1" colspan="1">4</td>
<td align="left" rowspan="1" colspan="1">3.78</td>
<td align="left" rowspan="1" colspan="1">sc</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Thalamus</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">12</td>
<td align="left" rowspan="1" colspan="1">−14</td>
<td align="left" rowspan="1" colspan="1">8</td>
<td align="left" rowspan="1" colspan="1">3.39</td>
<td align="left" rowspan="1" colspan="1">304</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Cerebellum</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">40</td>
<td align="left" rowspan="1" colspan="1">−78</td>
<td align="left" rowspan="1" colspan="1">−28</td>
<td align="left" rowspan="1" colspan="1">3.85</td>
<td align="left" rowspan="1" colspan="1">344</td>
<td align="left" rowspan="1" colspan="1">30</td>
<td align="left" rowspan="1" colspan="1">−54</td>
<td align="left" rowspan="1" colspan="1">−58</td>
<td align="left" rowspan="1" colspan="1">5.46</td>
<td align="left" rowspan="1" colspan="1">648</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">
<bold>OFF> ON</bold>
</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
</tbody>
</table>
</alternatives>
<table-wrap-foot>
<fn id="nt102">
<label></label>
<p>The coordinates (x,y,z) in standard Montreal Neurological Institute stereotaxic space for all significant activation peaks for SI compared with CTL movements. Cluster sizes are in mm
<sup>3</sup>
.</p>
</fn>
<fn id="nt103">
<label></label>
<p>BA, Brodmann area; R/L, right/left; aPFC, anterior prefrontal cortex; PMC, pre-motor cortex.</p>
</fn>
</table-wrap-foot>
</table-wrap>
</sec>
<sec id="s3c2">
<title>Externally triggered movements</title>
<p>For the ET vs. CTL contrast, patients ON showed significantly greater activity than OFF in the right motor cortex and left supplementary motor area (SMA), bilateral putamen and thalamus when using their left hand (
<xref ref-type="fig" rid="pone-0111600-g001">Figure 1</xref>
,
<xref ref-type="table" rid="pone-0111600-t004">Table 4</xref>
). For the right hand, patients ON showed significant increases in activity in the right cerebellum. Compared to the ON condition (OFF – ON contrast), patients OFF had significant increases in activity in the left motor cortex when using their right hand, and no significant differences in activity for the left hand.</p>
<table-wrap id="pone-0111600-t004" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0111600.t004</object-id>
<label>Table 4</label>
<caption>
<title>Activation peaks between patients ON and OFF performing ET compared with CTL movements.</title>
</caption>
<alternatives>
<graphic id="pone-0111600-t004-4" xlink:href="pone.0111600.t004"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
<col align="center" span="1"></col>
</colgroup>
<thead>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td colspan="5" align="left" rowspan="1">Left hand</td>
<td colspan="5" align="left" rowspan="1">Right hand</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Anatomical area</td>
<td align="left" rowspan="1" colspan="1">BA</td>
<td align="left" rowspan="1" colspan="1">R/L</td>
<td align="left" rowspan="1" colspan="1">x</td>
<td align="left" rowspan="1" colspan="1">y</td>
<td align="left" rowspan="1" colspan="1">z</td>
<td align="left" rowspan="1" colspan="1">t</td>
<td align="left" rowspan="1" colspan="1">cluster</td>
<td align="left" rowspan="1" colspan="1">x</td>
<td align="left" rowspan="1" colspan="1">y</td>
<td align="left" rowspan="1" colspan="1">z</td>
<td align="left" rowspan="1" colspan="1">t</td>
<td align="left" rowspan="1" colspan="1">cluster</td>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">
<bold>ON> OFF</bold>
</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Motor</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">24</td>
<td align="left" rowspan="1" colspan="1">−18</td>
<td align="left" rowspan="1" colspan="1">54</td>
<td align="left" rowspan="1" colspan="1">3.44</td>
<td align="left" rowspan="1" colspan="1">64*</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">SMA</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">L</td>
<td align="left" rowspan="1" colspan="1">−6</td>
<td align="left" rowspan="1" colspan="1">−6</td>
<td align="left" rowspan="1" colspan="1">52</td>
<td align="left" rowspan="1" colspan="1">3.44</td>
<td align="left" rowspan="1" colspan="1">136</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Putamen</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">L</td>
<td align="left" rowspan="1" colspan="1">−24</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">12</td>
<td align="left" rowspan="1" colspan="1">3.54</td>
<td align="left" rowspan="1" colspan="1">264</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">−30</td>
<td align="left" rowspan="1" colspan="1">−16</td>
<td align="left" rowspan="1" colspan="1">8</td>
<td align="left" rowspan="1" colspan="1">3.60</td>
<td align="left" rowspan="1" colspan="1">256</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">−32</td>
<td align="left" rowspan="1" colspan="1">−22</td>
<td align="left" rowspan="1" colspan="1">−4</td>
<td align="left" rowspan="1" colspan="1">3.47</td>
<td align="left" rowspan="1" colspan="1">104</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">22</td>
<td align="left" rowspan="1" colspan="1">2</td>
<td align="left" rowspan="1" colspan="1">14</td>
<td align="left" rowspan="1" colspan="1">3.99</td>
<td align="left" rowspan="1" colspan="1">296</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Thalamus</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">L</td>
<td align="left" rowspan="1" colspan="1">−12</td>
<td align="left" rowspan="1" colspan="1">−16</td>
<td align="left" rowspan="1" colspan="1">8</td>
<td align="left" rowspan="1" colspan="1">3.51</td>
<td align="left" rowspan="1" colspan="1">136</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">8</td>
<td align="left" rowspan="1" colspan="1">−14</td>
<td align="left" rowspan="1" colspan="1">8</td>
<td align="left" rowspan="1" colspan="1">3.97</td>
<td align="left" rowspan="1" colspan="1">388</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Cerebellum</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">R</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">30</td>
<td align="left" rowspan="1" colspan="1">−54</td>
<td align="left" rowspan="1" colspan="1">−58</td>
<td align="left" rowspan="1" colspan="1">3.89</td>
<td align="left" rowspan="1" colspan="1">240</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">
<bold>OFF> ON</bold>
</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Motor</td>
<td align="left" rowspan="1" colspan="1">6</td>
<td align="left" rowspan="1" colspan="1">L</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-</td>
<td align="left" rowspan="1" colspan="1">-20</td>
<td align="left" rowspan="1" colspan="1">−8</td>
<td align="left" rowspan="1" colspan="1">68</td>
<td align="left" rowspan="1" colspan="1">4.51</td>
<td align="left" rowspan="1" colspan="1">320</td>
</tr>
</tbody>
</table>
</alternatives>
<table-wrap-foot>
<fn id="nt104">
<label></label>
<p>The coordinates (x,y,z) in standard Montreal Neurological Institute stereotaxic space for all significant activation peaks for ET compared with CTL movements. Cluster sizes are in mm
<sup>3</sup>
.</p>
</fn>
<fn id="nt105">
<label></label>
<p>BA, Brodmann area; R/L, right/left; PMC, pre-motor cortex; SMA, supplementary motor area.</p>
</fn>
</table-wrap-foot>
</table-wrap>
</sec>
</sec>
</sec>
<sec id="s4">
<title>Discussion</title>
<p>The goal of this study was to examine the effect of levodopa on the neural patterns underlying asymmetrically affected hand movements in patients with PD. To our knowledge, this is the first direct evaluation of the impact of levodopa administration on behavioral and cerebral laterality. Surprisingly, although the literature suggests that PD patients tend to be more affected on their dominant side
<xref rid="pone.0111600-Uitti1" ref-type="bibr">[21]</xref>
<xref rid="pone.0111600-vanderHoorn1" ref-type="bibr">[22]</xref>
, the patients that participated in this study were mainly affected on the left, non-dominant side of the body. According to our results, levodopa had a preferential effect on brain activations in task-relevant brain areas during movements of the more affected hand. We found that regions involved in the motor cortico-striatal network (motor and pre-motor cortex, SMA, putamen and thalamus) and the cerebellum showed significant differences in activity between ON and OFF states when participants used their more affected (left) hand (
<xref ref-type="fig" rid="pone-0111600-g001">Figure 1</xref>
). In contrast, only the cerebellum showed significant differences ON vs. OFF when participants used their less affected (right) hand. Our results suggest that levodopa does not affect brain activity symmetrically, but rather, has a greater effect on the more affected side. There are two possible interpretations that are not necessarily mutually exclusive. First, as non-dominant hand movements are less automatic than dominant hand movements
<xref rid="pone.0111600-Mattay1" ref-type="bibr">[7]</xref>
, levodopa may provide additional resources necessary to execute the less automatic left hand movements. Alternatively, levodopa may have a stronger effect on left hand movements because it was the most affected side in our patient cohort.</p>
<p>One existing theory may help to explain these results. According to the ‘focusing theory’, levodopa would help focus otherwise spatially diffuse activity
<xref rid="pone.0111600-Ng1" ref-type="bibr">[24]</xref>
through an increase in signal-to-noise ratio by dopamine
<xref rid="pone.0111600-Winterer1" ref-type="bibr">[25]</xref>
. It is possible that dopamine facilitates activation of brain regions necessary for the generation of movements with the more affected limb. One positron emission tomography (PET) study in patients with PD at rest showed that levodopa decreased the PD-related pattern of brain metabolism by suppressing metabolic activity in the left motor cortex, putamen, right thalamus, and bilateral cerebellum
<xref rid="pone.0111600-Feigin2" ref-type="bibr">[26]</xref>
. Laterality effects were partially attributed to low statistical power; the authors speculated that the least affected side might have preferentially responded to levodopa because the nigrostriatal dopaminergic terminals of that side were less degenerated. Another group recently investigated the effect of a single dose of levodopa on a unimanual and bimanual grip task during fMRI in PD patients and healthy controls
<xref rid="pone.0111600-Kraft1" ref-type="bibr">[27]</xref>
. Levodopa significantly increased activity in the thalamus and putamen during bimanual movements. Although left side movements additionally recruited the ventrolateral thalamus, no significant differences between ON and OFF conditions were observed between the two hands. This may again be due to an effect of task. In summary, in accordance with the literature, our results suggest that there are differences in cerebral activity between the more and less affected sides.</p>
<p>One aspect worth mentioning is the lack of difference between reaction times in the ON and OFF states. On the contrary, when patients were ON medication, their reaction times for the control task were longer. It is important to note that the SI, ET and control tasks were not meant to test speed; participants were not instructed to perform as fast as possible. Rather, participants were asked to keep a steady, comfortable rhythm. For this reason, one possible explanation for the slower reaction times ON medication in the control task is that it is easier to keep a steady and regular pace than when OFF medication. In summary though, as expected, there were no significant differences in performance between ON and OFF conditions.</p>
<p>There seem to be considerable differences between the more and less affected hemispheres; asymmetrical degeneration of dopaminergic neurons in the substantia nigra underlies symptom asymmetry in PD
<xref rid="pone.0111600-Kempster1" ref-type="bibr">[28]</xref>
. It has been shown that the lateral ventricle contralateral to the more symptomatic side (i.e. the more affected hemisphere) is enlarged in PD patients with asymmetrical symptoms
<xref rid="pone.0111600-Lewis1" ref-type="bibr">[29]</xref>
, and cognitive disruption often is consistent with the symptomatic hemisphere
<xref rid="pone.0111600-Verreyt1" ref-type="bibr">[30]</xref>
. One study with
<italic>de novo</italic>
hemiparkinsonian patients looked that the effect of levodopa on cortical motor areas
<xref rid="pone.0111600-Buhmann1" ref-type="bibr">[31]</xref>
. Patients showed a hypoactivity in motor regions contralateral to the more affected hand, reversible with levodopa, whereas the side contralateral to the unaffected hand showed almost constant activity. Furthermore, responses to levodopa have been shown to vary throughout the course of the disease. More specifically, responses tend to be mild and long-lasting in the early stages of PD, followed by greater responses with shorter duration times in the later stages, and ending in abrupt on and off switches
<xref rid="pone.0111600-Duvoisin1" ref-type="bibr">[32]</xref>
. The response to levodopa on the left and right side of the body varies depending on the patients' asymmetry, implying that the asymmetrically affected hemispheres represent different stages of the disease. Using four different finger tapping tasks, one study demonstrated that the more affected side showed reduced response latency, greater magnitude of improvement and shorter response duration to an infusion of levodopa
<xref rid="pone.0111600-Rodriguez1" ref-type="bibr">[33]</xref>
. In addition, another study showed the more affected side to have a delayed onset after oral levodopa administration
<xref rid="pone.0111600-Kumar1" ref-type="bibr">[34]</xref>
. Based on the timing of our MRI acquisitions (1 h after levodopa administration), it is possible that the effect observed between ON and OFF is related to differences in levodopa response of the more and less affected hemispheres. Hence, there are important differences between the more and the less affected hemispheres, such as the response to levodopa. This difference in latency may be involved in the differences in cerebral activity we observe during the more and less affected hand movements.</p>
<p>We have recently shown that greater recruitment of the putamen is necessary to compensate for a lack of automaticity to a greater extent for left hand rather than right hand movements
<xref rid="pone.0111600-FrancoisBrosseau1" ref-type="bibr">[10]</xref>
in a study using SI, ET and control movements in young healthy right-handed participants. Based on these previous results, we speculated that the increase in putamen activity reached a ceiling when participants used their left hand, whereas gradual increases in activity could be observed from control to ET to SI movements when using the right hand. In patients with PD performing the same tasks with their right hand only, we have previously shown that differences in putamen activity between control, ET and SI tasks were reduced compared with older healthy controls, and that levodopa led to non-task-specific increases in cortico-striatal activity
<xref rid="pone.0111600-Martinu1" ref-type="bibr">[11]</xref>
. This was in accordance with a study investigating arm-reaching movements during PET imaging that showed that levodopa increased motor task-related activity
<xref rid="pone.0111600-Feigin1" ref-type="bibr">[12]</xref>
. Taken together, our results suggest that levodopa increases cortical and subcortical activity in the left hand condition due to increased difficulty using the more affected hand irrespective of the task being performed. However this may be a combined effect of disease laterality and hand proficiency.</p>
<p>Although we cannot conclusively attribute the effect of levodopa to the hand used and/or disease asymmetry, our results have important implications for the mechanisms underlying levodopa function and the treatment of asymmetrical PD symptoms. Follow-up studies with a full cross-over design including left- and right-handed patients with left- and right-disease asymmetry will be necessary to further disentangle the relationship between levodopa's effect on movements as a factor of handedness and symptom and cerebral lateralization.</p>
</sec>
</body>
<back>
<ack>
<p>The authors would like to thank the patients who participated in this study, Clotilde Degroot, Dr. Lafontaine and Dr. Chouinard for their assistance with patient recruitment, Cécile Madjar for statistical advice, Dr. Bradley King for valuable input on the manuscript, as well as Carollyn Hurst and André Cyr for their assistance at the Unité de Neuroimagerie Fonctionelle of the Centre de Recherche de l′Institut Universitaire de Gériatrie de Montréal.</p>
</ack>
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