Interrogating basal ganglia circuit function in Parkinson’s disease and dystonia

Reviewer #1 (Public Review):

Summary:
Sumarac et al investigate differences in globus pallidus internus (GPi) spike activity and short- and long-term plasticity of direct pathway projections in patients with Parkinson's disease (PD) and dystonia. Their main claims are that GPi neurons exhibit distinct characteristics in these two disorders, with PD associated with specific power-frequency oscillations and dystonia showing lower firing rates, increased burstiness, and less regular activity. Additionally, long-term plasticity and synaptic depression appear to differ between the two conditions. The authors suggest that these findings support the concept of hyperfunctional GPi output in PD and hypofunctional output in dystonia, possibly driven by variations in the plasticity of striato-pallidal synapses. Overall enthusiasm is relatively high, but I think the discussion omits discussing findings that don't align well with standard models.

Strengths:
These types of studies are valuable as the data arise from patients who have dystonia or PD. This could provide unique insights into disease pathophysiology that might not be recapitulated in animal systems work.

Weaknesses:
- The rate model and indirect/direct pathway ideas lack explanatory power; too much of the hypothesis generation and discussion in this manuscript is set in the context of these old ideas. Their data in my view emphasize this somewhat emphatically. Most patients with the 'hypokinetic' movement disorder PD have dystonia as a part of their motor features. Dystonia is a form of excessive muscle activation that on the one hand is 'hyperkinetic' but on the other usually decreases the speed of motor tasks, even in patients with primary dystonia. Similarly, PD patients display a bewildering variety of hyperkinetic manifestations as well (rest tremor, dystonia, dyskinesia). If these are truly independent classifications, i.e. hyper- versus hypo-kinetic, the authors must acknowledge that there is considerable overlap in the spike activity across groups - numerous dystonia patients display higher discharge rates than the majority of the PD sample. Based on the firing rate alone, it would not be possible to distinguish these groups.

- If beta power is pathognomonic of parkinsonism, the authors found no differences in beta-related spike discharges across the groups. One would have predicted greater beta power in PD than in primary dystonia. This should be discussed explicitly and an interpretation should be provided.

- The study lacks a healthy control group, making it challenging to differentiate disease-specific findings from normal variations in GPi activity and plasticity. Although this is acknowledged in the discussion, this complicates the interpretation of the results. The sample sizes for PD and dystonia patients are relatively small, and the study combines various forms of dystonia, potentially masking subtype-specific differences. A larger and more homogenous sample could enhance the study's reliability.

- While they mention that data are available on request, sharing data openly would increase transparency and allow for independent validation of the results. It is unclear how sharing deidentified data would compromise patient privacy or present ethical issues of any kind, as claimed by the authors.

- They appropriately acknowledge several limitations, such as the inability to use pharmacological interventions and the need for further research in the chronic setting.

- The manuscript highlights differences in GPi activity and plasticity between PD and dystonia but could provide more context on the clinical implications of these findings, particularly regarding what the implications would be novel paradigms for deep brain stimulation.

- While statistical tests are mentioned, the manuscript could benefit from a more detailed presentation of statistical methods, including correction for multiple comparisons and effect sizes. Did the authors consider different recording sites within each patient as independent observations? I think this is not appropriate if that was the case.

- The manuscript could elaborate on the potential mechanisms underlying the observed differences in GPi activity and plasticity and their relevance to the pathophysiology of PD and dystonia.

Reviewer #2 (Public Review):

Summary:
The authors investigated how neuronal activity and metrics of plasticity using local electrical stimulation in the GPi were different between Parkinson's disease and dystonia patients.

Strengths:
The introduction highlights the importance of the work and the fundamental background needed to understand the rest of the paper. It also clearly lays out the novelty (i.e., that the dynamics of plastic effects in GPi between dystonia and PD have not been directly compared).

The methods are clearly described and the results are well organized in the figures.

The results are strong with measurements from a large population of patients for each disease group and with distinct findings for each group.

Weaknesses:
The discussion was hard to follow in several places, making it difficult to fully appreciate how well the authors' claims and conclusions are justified by their data, mostly in relation to the plasticity results. It may help to summarize the relevant findings for each section first and then further expand on the interpretation, comparison with prior work, and broader significance. Currently, it is hard to follow each section without knowing which results are being discussed until the very end of the section. With the current wording in the "Neuronal correlates.." section, it is not always clear which results are from the current manuscript, and where the authors are referring to past work.

Also, I felt that more discussion could be used to highlight the significance of the current results by comparing and/or contrasting them to prior relevant work and mechanisms. The novelty or impact is not very clear as written. Could this be further substantiated in the Discussion?

Some specific comments and questions about the Discussion:
Lines 209-211 - This sentence was hard to understand, could it be clarified?
Lines 211-213 - What do phasic and tonic components mean exactly? Could this be specifically defined? Are there specific timescales (as referred to in Intro)?
Lines 215-217 - It's not clear what was delayed in dystonia, and how the authors are trying to contrast this with the faster time course in PD. I think some of this is explained in the introduction, but could also be re-summarized here as relevant to the results discussed.
Lines 223-224 - I'm not sure I follow the implication that network reorganization leads to delayed functional benefits. Could this be further elaborated?

Could the absence of a relationship between FR and disease in PD be discussed?

It wasn't very clear how the direct pathway can be attributed to plasticity changes if the GPi makes up both the direct and indirect pathways. Could this be further clarified?

The mechanism of short- and long-term plasticity as applied in the protocols used in this work are outlined in reference to previous citations [15, 16, 18]. Because this is a central aspect of the current work and interpreting the results, it was difficult to appreciate how these protocols provide distinct metrics of short and long-term plasticity in GPi without some explanation of how it applies to the current work and the specific mechanisms. It would also help to be able to better link how the results fit with the broader conclusions.

In the Conclusion, it was difficult to understand the sentence about microcircuit interaction (line 232) and how it selectively modulates the efficacy of target synapses. Some further explanation here would be helpful. Also, it was not clear how these investigations (line 237) provide cellular-level support for closed-loop targeting. Could the reference to closed-loop targeting also be further explained?

How is the burst index calculated (Methods)?

Figures and figure captions are missing some details:

Fig. 1 - What does shading represent?

Fig. 2 - Can the stimulation artifact be labeled so as not to be confused with the physiological signal? Is A representing the average of all patients or just one example? Are there confidence intervals for this data as it's not clear if the curves are significantly different or not (may not be important to show if just one example)? Same for D. What is being plotted in E? Is this the exponential fitted on data? Can this be stated in the figure citation directly so readers don't have to find it in the text, where it may not be directly obvious which figure the analyses are being applied towards?

What does shading here represent?