doi:10.1093/brain/awp156
Brain 2009: 132; 2327–2335
| 2327
BRAIN
A JOURNAL OF NEUROLOGY
Temporal Discrimination Threshold: VBM evidence
for an endophenotype in adult onset primary
torsion dystonia
1 Department of Neurology, St Vincent’s University Hospital, Dublin, Ireland
2 Trinity Centre for BioEngineering, Trinity College, Dublin, Ireland
3 Department of Neurophysiology, Beaumont Hospital, Dublin, Ireland
Correspondence to: Prof. Michael Hutchinson,
St Vincent’s University Hospital,
Elm Park, Dublin 4,
Ireland
E-mail: mhutchin@iol.ie
Correspondence may also be addressed to D. Bradley.
E-mail: david.bradley@ucd.ie
Familial adult-onset primary torsion dystonia is an autosomal dominant disorder with markedly reduced penetrance. Most
adult-onset primary torsion dystonia patients are sporadic cases. Disordered sensory processing is found in adult-onset primary
torsion dystonia patients; if also present in their unaffected relatives this abnormality may indicate non-manifesting gene
carriage. Temporal discrimination thresholds (TDTs) are abnormal in adult-onset primary torsion dystonia, but their utility as
a possible endophenotype has not been examined. We examined 35 adult-onset primary torsion dystonia patients (17 familial,
18 sporadic), 42 unaffected first-degree relatives of both familial and sporadic adult-onset primary torsion dystonia patients,
32 unaffected second-degree relatives of familial adult-onset primary torsion dystonia (AOPTD) patients and 43 control subjects.
TDT was measured using visual and tactile stimuli. In 33 unaffected relatives, voxel-based morphometry was used to compare
putaminal volumes between relatives with abnormal and normal TDTs. The mean TDT in 26 control subjects under 50 years
of age was 22.85 ms (SD 8.00; 95% CI: 19.62–26.09 ms). The mean TDT in 17 control subjects over 50 years was 30.87 ms
(SD 5.48; 95% CI: 28.05–33.69 ms). The upper limit of normal, defined as control mean + 2.5 SD, was 42.86 ms in the under
50 years group and 44.58 ms in the over 50 years group. Thirty out of thirty-five (86%) AOPTD patients had abnormal TDTs
with similar frequencies of abnormalities in sporadic and familial patients. Twenty-two out of forty-two (52%) unaffected firstdegree relatives had abnormal TDTs with similar frequencies in relatives of sporadic and familial AOPTD patients. Abnormal
TDTs were found in 16/32 (50%) of second-degree relatives. Voxel-based morphometry analysis comparing 13 unaffected
relatives with abnormal TDTs and 20 with normal TDTs demonstrated a bilateral increase in putaminal grey matter in unaffected
relatives with abnormal TDTs. The prevalence of abnormal TDTs in sporadic and familial AOPTD patients and their firstdegree relatives follows the rules for a useful endophenotype. A structural correlate of abnormal TDTs in unaffected first-degree
relatives was demonstrated using voxel-based morphometry. Voxel-based morphometry findings indicate that putaminal enlargement in AOPTD is a primary phenomenon. TDTs may be an effective tool in AOPTD research with particular relevance to genetic
studies of the disorder.
Received February 6, 2009. Revised March 23, 2009. Accepted May 6, 2009. Advance Access publication June 12, 2009
ß The Author (2009). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
For Permissions, please email: journals.permissions@oxfordjournals.org
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D. Bradley,1,2 R. Whelan,1,2 R. Walsh,1 R. B. Reilly,2 S. Hutchinson,1 F. Molloy3 and
M. Hutchinson1
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| Brain 2009: 132; 2327–2335
D. Bradley et al.
Keywords: dystonia; endophenotype; temporal discrimination; voxel-based morphometry; putamen
Abbreviations: AOPTD = Adult-onset primary torsion dystonia; SDT = spatial discrimination threshold; TDT = temporal
discrimination threshold
Introduction
Patients and Methods
TDT testing
AOPTD patients
Thirty-five AOPTD patients (17 familial, 18 sporadic) (mean age 53;
range 35–73) with focal dystonia (20 cervical dystonia, 13 focal hand
dystonia, one spasmodic dysphonia, one musician’s dystonia) were
recruited from our cohort at St Vincent’s University Hospital. The
clinical diagnosis of these patients was assessed using a videotaped
neurological examination reviewed by two neurologists with expertise
in dystonia. The majority of the familial patients came from six multiplex families; the index cases of these families were DYT1 negative.
The remaining patients did not have routine DYT1 screening in
keeping with guidelines (Bressman et al., 2000; Albanese et al.,
2006) as all had onset after the age of 26 years with no family history
of early-onset dystonia. Eighteen of the thirty-five patients were
receiving regular botulinum toxin injections for their dystonia. The
mean (SD) time since last injection in these 18 individuals was
8.2 (14.2) weeks.
Unaffected relatives
Forty-two first-degree relatives (26 of familial cases, 16 of sporadic
cases) and 32 second-degree relatives (all of familial cases) were
recruited (mean age 42 years; range 19–76). All were examined
clinically using a protocol for evidence of dystonia; none had any
evidence of dystonia or dystonic tremor.
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Adult-onset primary torsion dystonia (AOPTD) is the most
common form of dystonia; most patients appear to have sporadic
AOPTD but up to 25% of these have another affected family
member (Stojanovic et al., 1995; Leube et al., 1997). Familial
AOPTD is inherited in an autosomal dominant fashion with a
penetrance as low as 12%–15% (Waddy et al., 1991); the paucity
of multiplex AOPTD families makes genetic study of the disorder
difficult. The use of a sensitive endophenotype, a marker of
subclinical gene carriage in unaffected relatives, is one approach
to this problem.
Significant sensory processing abnormalities are found in
AOPTD patients including abnormalities in spatial discrimination
threshold (SDT), temporal discrimination threshold (TDT) and
vibration induced illusion of movement (VIIM) (Hallett, 1998;
Meunier et al., 2001; Fiorio et al., 2003, 2007; Molloy et al.,
2003; O’Dwyer et al., 2005; Walsh et al., 2007; Frima et al.,
2008). These sensory abnormalities may be of utility as endophenotypes. In addition, it has been proposed that abnormal sensory
processing may play a primary phenomenon in AOPTD, and may
play a role in the pathogenesis of AOPTD (Hallett, 1995; Tinazzi
et al., 2003).
SDTs are abnormal in some unaffected relatives of AOPTD
patients (O’Dwyer et al., 2005; Walsh et al., 2007) and have
been investigated as an endophenotype. However, the prevalence
of abnormal SDTs in AOPTD patients is low and a more sensitive
marker of gene carriage is needed which might significantly aid
genetic research.
The TDT is the shortest time interval at which a subject
can detect that two stimuli are asynchronous; TDT testing is
psycho-physiological task that is relatively easy to administer
with the advantage of showing significantly less age-dependence
than other candidate sensory tests in AOPTD such as SDTs
(O’Dwyer et al., 2005; Walsh et al., 2007). One study by
Hoshiyama and colleagues, for example, showed little effect of
age on TDT up to 65 years (Hoshiyama et al., 2004). The TDT
has been shown to be abnormal in DYT1 patients and nonmanifesting DYT1 carriers compared with non-carrier relatives or
controls (Fiorio et al., 2007). The TDT has also been shown to be
abnormal in patients with writer’s cramp (Fiorio et al., 2003),
blepharospasm (Fiorio et al., 2008), Parkinson’s disease (Artieda
et al., 1992; Lee et al., 2005) and multiple system atrophy
(Lyoo et al., 2007) and therefore may be a sensitive marker of
abnormal sensory integration in the basal ganglia. An early study
of temporal discrimination in subjects with focal cerebral lesions
found that TDT was increased without evident sensory loss in
lesions involving the putamen (Lacruz et al., 1991). fMRI studies
of both spatial and temporal discrimination tasks evoked basal
ganglia activation (Pastor et al., 2004), and during an auditory
temporal discrimination task activation in the basal ganglia
occurred early and was uniquely associated with encoding time
intervals (Rao et al., 2001). Pastor and colleagues suggested
that disorders affecting the basal ganglia would affect both spatial
and temporal discrimination (Pastor et al., 2004).
All these studies suggest that TDT may function as an
endophenotype in AOPTD by identifying subclinical basal ganglia
dysfunction; however, this has not been investigated by examining
both AOPTD patients and their unaffected relatives. The findings
that TDT abnormalities act as a marker of non-penetrant gene
carriage in unaffected relatives would be useful in performing
genetic studies of the disorder. The aim of this study was to
investigate the potential use of TDT as an endophenotype by
measuring the prevalence of TDT abnormalities in familial and
sporadic AOPTD patients, their unaffected relatives and healthy
control subjects. We hypothesized that an abnormal TDT in
clinically unaffected relatives of AOPTD patients is a marker of
subclinical gene carriage. We further sought to validate the
candidate endophenotype (TDT) by demonstrating a structural
correlate associated with abnormal TDTs in unaffected relatives
using voxel-based morphometry. We hypothesized that a
difference in putaminal volume would be found between
unaffected relatives with abnormal TDTs compared with those
with normal TDTs.
Temporal discrimination in AOPTD
Control participants
From hospital staff and visitors to the hospital, 43 healthy control
subjects were recruited. These were divided into two groups; under
50 years of age (n = 26; mean age 31 years; range 22–49) and over
50 years (n = 17; mean age 58 years, range 50–71). Exclusion criteria
were a history of neurological disease including neuropathy, visual
disorder or a history of cerebral, cervical or brachial plexus injury.
All subjects had normal cognition, normal visual acuity, absence of
sensory symptoms and a normal sensory examination.
Sensory testing
| 2329
relatives). All MRI scans were obtained at 1.5T on the same scanner
(Siemens Avanto, Erlangen, Germany). A high-resolution threedimensional T1-weighted magnetization-prepared rapid-acquisition
gradient echo (MPRAGE) sequence was acquired (TR = 1160 ms;
TE = 4.21 ms, TI = 600 ms, flip angle = 15 ) with a sagittal orientation,
a 256 256 matrix size and 0.9 mm isotropic voxels.
Analysis
Statistical parametric mapping software (SPM5; Wellcome Centre for
Neuroimaging, London, UK), running under Matlab 7 (Mathworks,
Sherborn, MA, USA), was used to pre-process and analyse the data.
Pre-processing incorporated image registration and classification into a
single generative model (Ashburner and Friston, 2005). Segmented
grey matter data were modulated in order to preserve volume. The
spatially normalized and modulated grey matter partitions were
smoothed using a 12mm full-width at half maximum Gaussian
kernel allowing parametric statistical analysis. Total grey matter
volume, age and sex were entered as nuisance covariates in all analyses. Analyses were restricted to a predefined region of interest—the
putamen—using anatomically defined masks (Wake Forest University
PickAtlas) (Maldjian et al., 2003). This software employs SPM5’s small
volume correction feature, reducing the number of multiple comparisons. Type I errors were controlled using false discovery rate
(FDR) of 0.05, which controls the expected proportion of false
positives among supra-threshold voxels for each analysis performed
(Genovese et al., 2002). The locations of significant voxels were
summarized by their local maxima separated by at least 8 mm, and
by converting the maxima coordinates from MNI to Talairach coordinate space. These coordinates were assigned neuroanatomic labels
using the Talairach Daemon brain atlas (Lancaster et al., 2000).
Ethical approval for this work was granted by the Ethics and
Medical Research Committee, St Vincent’s University Hospital, Elm
Park, Dublin 4, Ireland.
Results
TDTs
Analysis
Control subjects
The combined TDT score (the average of the results for the three task
types from both sides of the body) was used in analyses to assign
status to subjects; side of body and task type were also analysed as
within-subject factors. Unless otherwise stated, TDT refers to
combined TDT in the results and discussion. All statistical analyses of
behavioural data were conducted using Minitab 15. Groups (AOPTD
patients, unaffected relatives, healthy controls) were compared using
analysis of variance. Using the mean and SD of the TDTs of the
control group, standardized Z-scores were calculated for all subjects
using the formula;
There was a statistically significant effect of age on the combined
TDT score. Control subjects were divided into two groups under
50 years (n = 26; mean 31 years; range 22–49) and over 50 years
(n = 17; mean 58 years, range 50–71) to allow age-related normal
values to be calculated. The mean TDT in the under 50 control
group was 22.85 ms (SD 8.00; 95% CI: 19.62–26.09 ms). The
mean TDT in the over-50 control group was 30.87 ms (SD 5.48;
95% CI: 28.05–33.69 ms). The upper limit of normal, defined as
control mean + 2.5 SD, was 42.86 ms in the under 50 group and
44.58 ms in the over 50 group. All of the control subjects’ Z-scores
were 52.5 (range 2.21 to +1.76).
Z Score ¼
Actual TDT Age-related control mean TDT
Age-related control standard deviation
Z-scores of 52.5 were considered abnormal.
Voxel-based morphometry
Patients and methods
Structural MRI was acquired in 33 relatives (13 first-degree sporadic
relatives, 11 first-degree familial relatives, 9 second-degree familial
AOPTD patients
Thirty out of thirty-five (86%) AOPTD patients had abnormal
TDTs compared with controls; the frequency of abnormalities
was similar in sporadic (16/18; 89%) and familial (14/17; 82%)
patients (Fisher’s exact test; P = 0.658). There was also a similar
frequency of abnormalities when comparing cervical dystonia
(19/20; 95%) and focal hand dystonia (10/13; 77%) patients
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TDTs were examined in a single session in a sound proof, airconditioned room. TDTs were measured for three tasks: (i) visual–
visual: two LED lights were used, horizontally orientated and placed
on the table in front of the subject. The lights were seven degrees into
the subject’s peripheral vision on the side of the body being tested;
(ii) tactile–tactile: non-painful, above-threshold electrical stimulation
was used on the second and third fingers on the side of the body
being tested using square-wave stimulators (Lafayette Instruments
Europe, LE12 7XT, UK). Stimulus current was progressively increased
from zero in 0.1 mA steps to the lowest point at which the subject
could reliably detect the impulse (tested using a paradigm with
10 trials of randomly assigned real or sham impulses requiring a
response from the subject). Equality of stimulus intensity was then
established between the digits if necessary. The stimulus current
required ranged between 2 and 4.5 mA; and (iii) visual–tactile: a
combination of one LED light and stimulation of one finger on the
same side was used with the same equipment. Each of the three tasks
were performed four times on each side of the body in random order,
resulting in a total of 24 runs per subject. Task order was randomized
to minimize practice or attention effect. Pairs of stimuli were synchronized initially and were progressively separated in 5 ms steps. When
the subject reported that the pairs of stimuli were asynchronous on
three consecutive occasions, the first of these was taken as the TDT.
The median of the four runs for each of the six conditions (3 tasks 2
sides) was used for each subject to allow for practice effect and these
six results were averaged to obtain a summary (combined) TDT score.
Results of the combined TDT (in ms) are shown with their standard
deviation (SD) and 95% confidence intervals (CI).
Brain 2009: 132; 2327–2335
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D. Bradley et al.
subjects ranging from 2.21 to 1.76 are illustrated in the
column on the left. Thirty out of thirty-five (86%) AOPTD
patients (17 familial; 18 sporadic), 22 of 42 (52%) first-degree
relatives (26 familial; 16 sporadic) and 16 of 32 second-degree
relatives (all familial) had abnormal TDTs using a cutoff of
2.5 SDs (Z-score = 2.5) above the control mean (dotted line).
(1ST DEGREE RELATIVES = Unaffected first-degree relatives of
AOPTD patients; 2ND DEGREE RELATIVES = Unaffected
second-degree relatives of AOPTD patients.)
(Fisher’s exact test; P = 0.276). In the 18 patients treated with
botulinum toxin, there was no statistical correlation between
TDT and time since last botulinum toxin injection.
Unaffected relatives
The frequency of TDT abnormalities amongst the first-degree
relatives was 52% (22/42); the frequencies in familial relatives
(15/26; 57%) and sporadic relatives (7/16; 44%) were similar
(Fisher’s exact test; P = 0.527). Sixteen of thirty-two seconddegree relatives had abnormal TDTs (Figs 1 and 2, Table 1).
Group differences
The mean TDT in the patient group was 70.32 ms (SD 26.87;
95% CI: 61.09–79.55 ms) and in the relatives group was 52.29
ms (SD 24.15; 95% CI: 46.69–57.88 ms). The TDTs in AOPTD
patients, unaffected relatives and control subjects were statistically
significantly different [one-way non-parametric ANOVA
P50.0001; post hoc comparisons using Tukey 99% simultaneous
confidence intervals showed that all three groups (patients,
relatives and controls) were statistically different from each
other]. When analysed as a within-subject factor, side of body
was non-significant.
Individual tasks
The combined TDT results in Figs 1 and 2 and Table 1 present the
mean of the measurements for the three individual tasks (visual,
tactile and mixed). When analysed as a within-subject factor in the
control group, task type was not significant [F(2,84) = 2.242;
P = 0.095]. The combined TDT was chosen to assign TDT status
as a mechanism of increasing sensitivity as it uses all of the
available temporal discrimination data for each subject. However,
Figure 2 Comparison of the frequencies of abnormal TDTs
found in familial and sporadic AOPTD subjects, their relatives
and in AOPTD phenotypes. The Z-scores of 43 healthy control
subjects are illustrated in the column on the left. The upper
limit of 2.5 SDs (Z-score = 2.5) is illustrated by the dotted
horizontal line. (A) TDT Z-scores in familial and sporadic
AOPTD patients and their relatives. The frequencies of
abnormal TDTs were the similar in both familial (14/17) and
sporadic (16/18) AOPTD patients. The frequency of abnormal
TDTs was similar in familial (15/26) and sporadic (7/16)
first-degree relatives (SPORADIC 1ST RELATIVES = Unaffected
first-degree relatives of sporadic patient; FAMILIAL 1ST
RELATIVES = Unaffected first-degree relatives of familial
AOPTD Patient; 2ND DEGREE RELATIVES = Unaffected
second-degree relatives of familial AOPTD patient). (B) TDT
Z-scores in Cervical Dystonia and Writer’s Cramp. The
frequencies of abnormal TDTs were similar in both cervical
dystonia (19/20) and writer’s cramp (10/13) patients.
task type was a significant within-subject factor in the patient
[F(2,64) = 5.460; P = 0.006] and relative [F(2,144) = 18.105;
P50.0001] groups. In keeping with similar studies (Fiorio et al.,
2007, 2008), the visual task had the lowest TDT followed by the
tactile and then the mixed task. Concordance (all three individual
task results in a particular subject being 52.5 SD ‘normal’ or 42.5
SD ‘abnormal’) was not 100%. In using the combined TDT score,
some subjects who did not reach the 2.5 SD threshold for
abnormality in one task were still assigned abnormal status
because the combined result for the three tasks exceeded the
cutoff (i.e. some subjects categorized as having an abnormal
combined TDT had a Z-score52.5 for one of the three tasks).
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Figure 1 Z-scores for TDT. The Z-scores of 43 healthy control
Temporal discrimination in AOPTD
Brain 2009: 132; 2327–2335
Table 1 Summary of TDT testing showing, in
milliseconds, mean, SD and 95% CI for each group
of control subjects under 50 years and over 50 years,
AOPTD patients and their unaffected relatives
Control under 50 years
Control over 50 years
AOPTD patients
Unaffected relatives
n
Mean TDT (SD)
95% CI
26
17
35
74
22.85
30.87
70.32
52.29
19.62–26.09
28.05–33.69
61.09–79.55
46.69–57.88
(8.00)
(5.48)
(26.87)
(24.15)
All patients
Cervical dystonia
Writer’s cramp
Spasmodic dysphonia
Musician’s dystonia
n
Visual
TDT
Tactile
TDT
Mixed
TDT
Combined
TDT
35
20
13
1
1
86%
95%
77%
0/1
1/1
85%
89%
83%
0/1
1/1
67%
75%
62%
0/1
1/1
86%
95%
77%
0/1
1/1
The combined TDT was chosen as it allowed the use of the most temporal
discrimination data on an individual subject (see text for discussion).
and willing to undergo TDT measurement for the present study.
The three remaining familial AOPTD subjects had only one other
family member affected. All of the familial unaffected relatives
of AOPTD patients (26 first degree and 32 second degree)
belonged to the six multiplex families; 15 of 26 unaffected
first-degree relatives and 16 of 32 second-degree relatives had
abnormal TDTs.
Three of the family trees with the TDT Z-scores for each family
member examined are illustrated (Fig. 4A–C). It is noteworthy that
in pedigree 006 (Fig. 4C) one family member (II:2) was clinically
unaffected, but was regarded as an obligate carrier due to having
an affected child (III:8) and an affected sibling (II:6), this obligate
carrier had an abnormal TDT (Z = 9.4). Two individuals in pedigree
008 (IV:3 and IV:4) and two in pedigree 006 (II:3 and III:5) who
were clinically unaffected with affected siblings were considered
obligate endophenotype carriers as some of their clinically
unaffected offspring had abnormal TDTs; these obligate endophenotype carriers also had abnormal TDTs.
Using TDT testing in 72 individuals in the six families, 29 had
normal TDT Z-scores, one of whom had spasmodic dysphonia
and 43 abnormal TDT Z-scores were identified in 12 affected
individuals, one obligate carrier and 30 other unaffected relatives
(14 first-degree and 16 second-degree). Thus in these six families
using TDT as an endophenotype, we were able to identify more
than twice as many endophenotype carriers as clinically manifesting individuals. No individual who had a normal TDT was found to
have an offspring with an abnormal TDT.
Voxel-based morphometry study
The three TDT tasks were assessed separately in terms of
frequency of abnormalities (Table 2, Supplementary data 1). In
AOPTD patients, the combined TDT had a sensitivity of 86%.
The sensitivity of an abnormal visual TDT was 86%, of an
abnormal tactile TDT was 85% and of an abnormal mixed TDT
was 67%. Comparing cervical dystonia and writer’s cramp
patients, the frequencies of abnormalities were similar for the
visual task (Fisher’s exact test; P = 0.276), tactile task (Fisher’s
exact test; P = 0.630) and mixed task (Fisher’s exact test;
P = 0.461). The frequencies of abnormal visual TDT, tactile TDT
and mixed TDT in unaffected first-degree relatives were 50, 45
and 46%, respectively; the frequency of abnormalities using the
combined TDT was 52%. The concordance [all three individual
task results in a particular subject being 52.5 SD (normal) or 42.5
SD (abnormal)] in control subjects was 100%. Concordance was
lower in AOPTD patients (76%) and unaffected relatives (77%).
Temporal discrimination in AOPTD
families
Fourteen of the seventeen familial AOPTD subjects tested for TDT
came from six multiplex families in which at least three family
members were clinically affected; 12 of these 14 had abnormal
TDTs. These six families were identified and characterized several
years ago by our department (O’Dwyer et al., 2005); as a result of
relocation, illness and other factors only a limited number of the
previously examined individuals in these pedigrees were available
Of the 33 unaffected relatives of AOPTD patients who had MRI
scanning, 13 had an abnormal TDT (Z-score42.5) and 20 had
normal TDTs (Z-score52.5). The mean age in of the abnormal
TDT group was 41.7 years and the mean age in the normal TDT
group was 38.1 years. The age difference between the groups was
not statistically significantly different [t (21) = 1.11, P40.05].
The mean TDT Z-score of the normal TDT group was 0.51
(range 1.83 to 2.40) and the mean TDT Z-score of the abnormal
TDT group was 5.9 (range 3.39–12.68). Results are reported with
Z-value, 5% FDR P-value and Talairach x, y, z coordinates in
parentheses. Relatives with abnormal TDTs had significantly
greater putaminal grey matter volume compared with relatives
with normal TDT in the left putamen (Z = 3.75, PFDR = 0.016,
x = 26, y = 14, z = 2) and right putamen (Z = 3.00, PFDR = 0.021,
x = 24, y = 16, z = 4), (Fig. 3).
Discussion
In this study, we have found abnormal TDTs in 86% of patients
with AOPTD with similar frequencies in sporadic (16/18; 89%)
and familial (14/17; 82%) patients. In addition, 52% of unaffected first-degree relatives of AOPTD patients (familial relatives
15/26; 57% and sporadic relatives 7/16; 44%) had abnormal
TDTs. Unaffected relatives with abnormal TDTs were found to
have increased putaminal volume when compared with relatives
with normal TDTs. An ideal endophenotype for an autosomal
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Table 2 Summary of the relative sensitivities of the
individual TDT tasks and the combination in AOPTD
patients with cervical dystonia (n = 20), writer’s cramp
(n = 13), spasmodic dysphonia (n = 1) and musician’s
dystonia (n = 1)
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D. Bradley et al.
coordinates in parentheses) showing increased volume of the anterior and posterior putamen on the left side (Z = 3.75, PFDR = 0.016,
x = 26, y = 14, z = 2) and right side (Z = 3.00, PFDR = 0.021, x = 24, y = 16, z = 4) in unaffected AOPTD relatives with abnormal
TDTs in comparison with relatives with normal TDTs.
dominant disorder should be abnormal in 100% of affected
individuals, 50% of first-degree relatives and in no control subjects; the frequency of abnormal TDTs in this study are in line with
these values. TDT scores of the control subjects were closely
grouped around the mean of 22.85 ms (SD 8.00 ms) under 50
years and 30.87 ms (SD 5.48 ms) over 50 years and no control
subject had a TDT Z-score4+2.0; thus the occurrence of TDT
Z-scores42.5 in the AOPTD patients and relatives can be
regarded as reliably abnormal.
The concordance among the three individual TDT tasks was
lower in AOPTD patients (76%) and unaffected relatives (77%)
than in control subjects, who had 100% concordance. There was
a higher frequency of abnormal results using the combined TDT
compared with any individual task. Using the combined TDT,
abnormal status was assigned in some subjects with abnormalities
in two TDT tasks when the third TDT task was normal. For example, 52% of the group of first-degree relatives had abnormal
status using combined TDT, while the proportions who had an
abnormal visual and tactile TDT were 50 and 45%, respectively.
In considering the use of TDT as a practical endophenotype, it is
interesting to note that the frequencies of abnormalities in Cervical
Dystonia and Writer’s Cramp (Table 2) were not significantly
different. This suggests that the usefulness of TDT task type
does not vary between phenotypes—a finding consistent with
TDT being a state-independent endophenotype. In addition, the
lower sensitivity of the mixed TDT task (Table 2) suggests that it
could be omitted in order to produce a simpler experimental
design for application as an endophenotype. Our TDT values in
the healthy control subjects are in keeping with other published
work; Hoshiyma and colleagues (2004) described a study of TDTs
in 80 healthy volunteers and reported a mean TDT of 26.1 ms at
the index finger. Tinazzi and colleagues (1999) reported a control
TDT of 35.48 ms in a study of idiopathic dystonia. The mean TDT
in our control subjects was lower than the range of 58–68 ms
reported by Fiorio and colleagues (2003, 2007, 2008). There are
some methodological differences in that we chose the median for
each task/side combination to attenuate practice effects and
recorded at 5 ms steps in our protocol. The protocol used to
measure TDT is a major determinant of performance. For example,
an auditory task generally results in better performance (Grondin
et al., 2004). Using a more sophisticated technique, Giersch et al.
(2008) described recording of TDTs using visual stimuli with and
without distracters or priming. They found that without distracters,
the mean TDT amongst controls was 25 ms while with distracters (additional lights) or primers (pre-judgement presentation
of lights), the mean amongst controls rose to between 50 and
70 ms. Therefore, the results of studies using different protocols
or equipment are not directly comparable and thresholds are
only precisely applicable within each individual experimental
paradigm.
Our novel findings of bilaterally increased putaminal volume
when comparing asymptomatic relatives with abnormal TDTs
to those with normal values further supports and validates the
endophenotype. Increased putaminal volume is a consistent
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Figure 3 Results of the voxel-based Morphometry (VBM) analysis (results reported with Z-value, 5% FDR P-value and Talairach x, y, z
Temporal discrimination in AOPTD
| 2333
Figure 4 Examples of the TDT testing in three of the six
familial AOPTD pedigrees. Affected individuals are represented
by filled icons and obligate carriers by half-filled icons. All
individuals tested for TDT have a coloured central dot
(green = normal TDT, Z52.5; red = abnormal TDT, Z42.5)
with individual TDT Z-scores shown. Subjects who have been
examined clinically (some of whom were not available for
TDT testing) have a horizontal line above their icon. (A) In a
sub-pedigree of pedigree 008, the autosomal dominant
transmission of the endophenotype is illustrated; IV:3 and
IV:4 have abnormal TDTs and have transmitted the TDT
endophenotype to their children V:5,V:7 and V:8- V:11, V:13.
(B) In pedigree 010, the usefulness of TDT is illustrated. In
addition to the four clinically affected individuals (II:3, II:5, II:6
III:13), five unaffected relatives with abnormal TDTs (II:2, II:4,
III:6, III:7, III:17) are identified along with six unaffected
relatives with normal TDTs who may be included in a genetic
analysis. (C) In pedigree 006, an unaffected obligate carrier
(II:2) with an affected sibling (II:6) and offspring (III:8) has
an abnormal TDT (Z = 9.4). Both II:6 and III:8 have cervical
dystonia. In this pedigree, one individual with spasmodic
dysphonia (III:22) has a normal TDT (Z-score 1.9). Autosomal
dominant transmission of abnormal TDTs is demonstrated from
II:3 to three of five offspring (III:10, III:11 and III:14) and from
II:5 to 1 of 4 examined offspring (III:21).
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finding associated with manifesting AOPTD patients including
those with idiopathic blepharospasm (Etgen et al., 2006), focal
hand dystonia and cranial dystonia (Black et al., 1998). We
have, therefore, demonstrated a disease-associated phenomenon
in individuals with the candidate endophenotype. An fMRI study
of temporal processing of an auditory task showed that initial
activation occurs in the striatum, particularly the putamen,
followed later by more diffuse activation (Rao et al., 2001), lending support to the hypothesis that the basal ganglia, and possibly
dopaminergic pathways in particular (Malapani et al., 1998), act
as a basic time processor in the CNS. Further fMRI studies have
confirmed the central role of the putamen in temporal processing
and have found activation lateralized to the right hand side
(Nenadic et al., 2003; Pastor et al., 2008). Interestingly, Pastor
et al. (2008) also demonstrated that activation in the putamen
decreases with perceptual difficulty suggesting it is primarily
involved in automatic perception of time. We postulate, therefore,
that a disorder of sensory integration in the basal ganglia involving
the putamen in particular is the patho-physiological basis of abnormal temporal discrimination in these individuals.
There are many outstanding questions relating to the multitude
of abnormal experimental findings in AOPTD and whether these
represent primary phenomena or secondary features of disease
manifestation (Breakefield et al., 2008). Our novel demonstration
of increased putaminal volume in asymptomatic relatives with
abnormal temporal processing is helpful in this regard. This finding
suggests that putaminal enlargement is a primary phenomenon in
AOPTD gene carriers and is associated with abnormal temporal
processing in contrast to the suggestion that putaminal enlargement in AOPTD is secondary to abnormal dystonic motor activity
(Etgen et al., 2006). Further studies using TDTs in AOPTD asymptomatic relatives may prove useful in defining the primary and
secondary features of AOPTD. These studies could utilize fMRI
or PET to measure functional processing and diffusion tensor
imaging (DTI) to examine dynamic pathways.
The mean age of the relatives with abnormal TDTs was
3.7 years older than the relatives with normal TDT, a nonsignificant difference. The greater putaminal volume found in
the abnormal TDT relatives group cannot be attributed to this
difference for two reasons: age was included as a nuisance
variable in the voxel-based morphometry analysis and the
human putamen has an annual rate of shrinkage of 0.73%
(Raz et al., 2003).
Support for the concept that an abnormal TDT represents
an endophenotype comes from study of DYT1 families in which
non-manifesting carriers of the gene had abnormal TDTs whereas
the non-carrier relatives had normal TDT (Fiorio et al., 2007). Thus
sensory abnormalities as an endophenotype can be present in
carriers of a dystonia gene without clinical manifestation of the
disorder. In our study, the similar frequencies of TDT abnormalities
in unaffected relatives of both sporadic and familial AOPTD
patients, suggest that apparently sporadic AOPTD patients are
the only manifesting carrier of poorly penetrant familial AOPTD.
The finding that an obligate carrier examined by TDT had an
abnormal Z-score is strong supportive evidence that an abnormal
TDT represents an endophenotype. Autosomal dominant transmission of abnormal TDTs was demonstrated in the multiplex
Brain 2009: 132; 2327–2335
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| Brain 2009: 132; 2327–2335
pedigrees and no parent with a normal TDT had an offspring with
an abnormal TDT. Heretofore, the lack of informative families has
hampered genetic research in AOPTD; the TDT endophenotype
may strengthen the power of linkage analysis studies (Fig. 4). TDT
could be used to define two groups in AOPTD families; gene
carriers (AOPTD patients and unaffected relatives with abnormal
TDTs) and non-carriers (unaffected relatives with normal TDTs).
In this way, the power of a genetic study may be significantly
improved. Alternatively, TDT could increase the numbers available
for a transmission disequilibrium study (Defazio et al., 2006) by
assigning gene carrier status based on TDT rather than disease
manifestation alone.
The high prevalence of TDT abnormalities in both familial
and sporadic AOPTD patients and their unaffected relatives, the
finding of abnormal TDTs in obligate heterozygotes and the
autosomal dominant pattern of transmission suggest that TDT is
a sensitive endophenotypic marker for AOPTD. Voxel-based morphometry further validates the hypothesis that TDT can effectively
fulfil the role of a sensitive marker of subclinical gene carriage in
AOPTD. The presence of increased putaminal volume in clinically
unaffected relatives with abnormal TDT in this study supports
the hypothesis that increased putaminal volume in AOPTD is a
primary phenomenon. The similar frequency of abnormal TDTs
in relatives of sporadic and familial AOPTD patients suggests
that in sporadic AOPTD patients the affected individual is
the only manifesting carrier of a poorly-penetrant genetic
disorder. TDT testing is likely to be a useful tool in AOPTD genetic
research.
Supplementary material
Supplementary material is available at Brain online.
Acknowledgement
Dystonia Ireland is a non-profit patient support organization.
Funding
Dystonia Ireland (www.dystonia.ie).
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