Disturbance of sequential movements in patients with Parkinson's disease.

The following sequences of two single movements were examined in 10 patients with Parkinson's disease and compared with the performance of 9 normal subjects of similar age. Isometric opposition of thumb and fingers to a force of 30 N ('squeeze'), followed by isotonic elbow flexion ('flex') through 15 degrees with the same arm. 'Squeeze' with the left hand followed by 'flex' with the right elbow. Isotonic opposition of thumb and fingers ('cut') through 90 degrees followed by isotonic 'flex' with the same arm. Isotonic elbow 'flex' followed by isometric 'squeeze' with the same arm. All movements were self-paced. Subjects were given instructions to move as rapidly as possible and to start the second movement immediately after the end of the first. Patients were slower than normal when each single movement was performed separately. There was a further decrease in speed when two movements were executed sequentially. This was due to an increase in movement duration of each of the component movements, especially the second, and to an increase in the pause between the first and second movements. In both normals and patients, there was no correlation between the times taken to perform the first and second movements of any of the four sequences that were studied. Because of this we suggest that the two components of the sequence remained under the control of two separate motor programs. When performing the sequential tasks, normal subjects automatically chose an interval between the onsets of the two separate movements of about 230 ms, even in tasks in which the duration of the first movement was less than 200 ms. If normal subjects were instructed to begin the second movement with an interonset interval of less than 200 ms, the speed of the second movement was much slower. Patients with Parkinson's disease automatically chose a much longer interonset interval of 400-500 ms. In addition, they exhibited difficulty in switching from the first to the second movement in the sequence. We suggest that the problems exhibited by patients with Parkinson's disease when they try to perform two rapid sequential movements can be seen as a deficit in the capacity to switch from one motor program to another within an overall motor plan.