ABSTRACT
BACKGROUND AND PURPOSE: The aim of this study was to assess the possible pharmacological interactions between safinamide and antidepressants, and in particular the appearance of serotonin syndrome with data from real life. METHODS: We conducted a retrospective observational study of patients with Parkinson's disease from our Movement Disorders Unit, who were under treatment with any antidepressant drug and safinamide. Specifically, symptoms suggestive of serotonin syndrome were screened for. Also, we collected time of simultaneous use, doses of levodopa and other antiparkinsonian drugs. RESULTS: Clinical records were reviewed for the study period of September 2018 to September 2019. Seventy-eight PD patients who were treated with safinamide of which 25 (32.05%) had a concomitant treatment with an antidepressant drug, being sertraline and escitalopram the most frequent. Mean age was 80 years±8.43 and H&Y stage was 3 [2-4]. Mean dose of levodopa used was 703.75mg±233.15. Median duration of concomitant treatment with safinamide and antidepressant drug was 6 months (IQR 20.5), and over eighteen months in 5 cases. No case of serotonin syndrome was recorded, neither was any of its typical manifestations combined or in isolation. CONCLUSIONS: Our real clinical practice study suggests that concomitant use of safinamide with antidepressant drugs in PD patients seemed to be safe and well tolerated, even in the long term. However, caution is warranted, individualizing treatment regimens and monitoring the potential appearance of adverse effects.
Subject(s)
Alanine , Benzylamines , Parkinson Disease , Serotonin Syndrome , Aged, 80 and over , Humans , Alanine/analogs & derivatives , Antidepressive Agents/adverse effects , Levodopa/therapeutic use , Parkinson Disease/drug therapy , Aged , Drug InteractionsABSTRACT
INTRODUCTION: Functional neurological disorders (FND) are a frequent reason for visits in neurology. However, specific training on these disorders during undergraduate and residency training is limited. This study assesses the knowledge, attitude and exposure of medical students to FNDs before completing their medical degree. PATIENTS AND METHODS: We conducted a 15-item survey to explore understanding, exposure and attitudes towards FNDs among sixth-year medical students at four Spanish universities. RESULTS: A total of 118 students (mean age 23.6 ± 1.2 years; 71.2% female) returned the survey. Of these, 88 (74.6%) were aware of the concept of FNDs and 78 (66.1%) had studied them in psychiatry classes. The term 'psychosomatic' was chosen by 54.1% of the students as the most appropriate term to refer to these disorders, and 111 (94.1%) believed that a history of sexual or physical abuse was common among FND patients. Fifty-seven students (48.3%) assumed that the diagnosis of FND was mostly a clinical diagnosis of exclusion and 63 (53.4%) indicated that it is managed only by psychiatry. One hundred and one students (85.6%) considered that adequate training on FNDs is an important aspect of their medical training. CONCLUSIONS: Medical students are aware of the existence of FNDs, but their preferred terminology, as well as the perceived aetiological factors, reflect that the historical view of these disorders is still deeply rooted. Medical students feel that they should receive adequate education on FNDs from specialists in neurology and psychiatry as part of their training.
TITLE: ¿Qué piensan los estudiantes de Medicina sobre los trastornos neurológicos funcionales?Introducción. Los trastornos neurológicos funcionales (TNF) son un motivo de consulta frecuente en neurología. Sin embargo, la formación específica sobre estos trastornos durante la formación universitaria y el período de residencia es limitada. En este estudio se evalúan los conocimientos, la actitud y la exposición de los estudiantes de Medicina a los TNF antes de terminar el grado de Medicina. Sujetos y métodos. Realizamos una encuesta de 15 ítems para explorar la comprensión, la exposición y las actitudes hacia los TNF entre los estudiantes de Medicina de sexto año en cuatro universidades españolas. Resultados. Devolvieron la encuesta 118 estudiantes (edad media 23,6 ± 1,2 años; 71,2%, mujeres). De ellos, 88 (74,6%) conocían el concepto de TNF y 78 (66,1%) los habían estudiado en las clases de psiquiatría. El 54,1% de los estudiantes eligió el término 'psicosomático' como el más adecuado para referirse a estos trastornos, y 111 (94,1%) creían que una historia de abuso sexual o físico era común entre los pacientes con TNF. Cincuenta y siete estudiantes (48,3%) asumieron que el diagnóstico de TNF era mayoritariamente un diagnóstico clínico de exclusión y 63 (53,4%) señalaron que el manejo se realiza únicamente desde psiquiatría. Ciento un estudiantes (85,6%) consideraron que una formación adecuada sobre los TNF es un aspecto importante de su formación médica. Conclusiones. Los estudiantes de Medicina son conscientes de la existencia de los TNF, pero la terminología preferida por ellos, así como los factores etiológicos percibidos, reflejan que la visión histórica acerca de estos trastornos está aún arraigada. Los estudiantes de Medicina consideran que deberían recibir una educación adecuada sobre los TNF como parte de su formación por parte de los especialistas en neurología y psiquiatría.
Subject(s)
Conversion Disorder , Neurology , Students, Medical , Humans , Female , Young Adult , Adult , Male , Attitude of Health Personnel , Neurology/education , Surveys and QuestionnairesABSTRACT
INTRODUCTION: Unilateral Gamma Knife™ stereotactic radiosurgery on the ventral-intermediate nucleus of the thalamus is a minimally invasive neurosurgical option for refractory tremor. We describe the experience of Gamma Knife™ thalamotomy (GKT) in patients with essential tremor (ET) and tremor-dominant Parkinson's disease (PD) at our specialised stereotactic neurosurgery unit. METHODS: We reviewed the cases of patients treated with GKT between January 2014 and February 2018 with a minimum of 12 months' follow-up. We analysed clinical and demographic variables, indication, radiation dose, effectiveness (based on subscales of the Fahn-Tolosa-Marin [FTM] scale and the Movement Disorders Society-Unified Parkinson's Disease Rating Scale [MDS-UPDRS] motor score), and adverse events. RESULTS: Thirteen patients were registered, 6 with a diagnosis of tremor-dominant PD, four with refractory ET, and three with ET and PD. Median age was 78 years (range, 62-83), with seven patients aged over 75 years. Four patients were receiving anticoagulants and two had history of stroke. The maximum radiation dose administered was 130 Gy. Mean (standard deviation) follow-up duration was 30.0 (14.5) months. Significant tremor improvement was observed on the FTM subscales: 63.6% at 12 months and 63.5% at the end of follow-up; MDS-UPDRS tremor items showed improvements of 71.3% at 12 months and 60.3% at the end of follow up. Eleven patients reported significant improvements in quality of life, and 3 reported mild and transient adverse effects. CONCLUSIONS: This is the largest series of patients with essential and parkinsonian tremor treated with GKT and followed up in the long term in Spain. GKT can be safe and effective in the long term in patients with refractory tremor, including in elderly patients and those receiving anticoagulants.
Subject(s)
Essential Tremor , Parkinson Disease , Radiosurgery , Aged , Humans , Tremor/etiology , Treatment Outcome , Quality of Life , Radiosurgery/adverse effects , Follow-Up Studies , Magnetic Resonance Imaging , Essential Tremor/radiotherapy , Essential Tremor/etiology , Essential Tremor/surgeryABSTRACT
BACKGROUND AND PURPOSE: The aim of this study was to assess the possible pharmacological interactions between safinamide and antidepressants, and in particular the appearance of serotonin syndrome with data from real life. METHODS: We conducted a retrospective observational study of patients with Parkinson's disease from our Movement Disorders Unit, who were under treatment with any antidepressant drug and safinamide. Specifically, symptoms suggestive of serotonin syndrome were screened for. Also, we collected time of simultaneous use, doses of levodopa and other antiparkinsonian drugs. RESULTS: Clinical records were reviewed for the study period of September 2018 to September 2019. Seventy-eight PD patients who were treated with safinamide of which 25 (32.05%) had a concomitant treatment with an antidepressant drug, being sertraline and escitalopram the most frequent. Mean age was 80 years±8.43 and H&Y stage was 3 [2-4]. Mean dose of levodopa used was 703.75mg±233.15. Median duration of concomitant treatment with safinamide and antidepressant drug was 6 months (IQR 20.5), and over eighteen months in 5 cases. No case of serotonin syndrome was recorded, neither was any of its typical manifestations combined or in isolation. CONCLUSIONS: Our real clinical practice study suggests that concomitant use of safinamide with antidepressant drugs in PD patients seemed to be safe and well tolerated, even in the long term. However, caution is warranted, individualizing treatment regimens and monitoring the potential appearance of adverse effects.
ABSTRACT
INTRODUCTION: Parkinson's disease (PD) is more frequent in the elderly and increases the risk of respiratory infections. Previous data on PD and SARS-CoV-2 are scarce, suggesting a poor prognosis in advanced disease and second-line therapies. METHODS: A retrospective case-control study comparing patients with PD and COVID-19 and patients with PD without COVID-19 was conducted during the pandemic period in Spain (March 1st-July 31st 2020) in a tertiary university hospital. RESULTS: Thirty-nine (COVID-19 +) and 172 (COVID-19-) PD patients were included. Fifty-nine percent were males in both groups, with similar age (75.9 ± 9.0 COVID-19 + , 73.9 ± 10.0 COVID-19-), disease duration (8.9 ± 6.2 COVID-19 + , 8.5 ± 5.6 COVID-19-) and PD treatments. COVID-19 was mild in 10 (26%), required admission in 21 (54%) and caused death in 8 (21%) patients. Dementia was the only comorbidity more frequent in COVID-19 + patients (36% vs. 14%, p = 0.0013). However, in a multivariate analysis, institutionalization was the only variable associated with COVID-19 + (OR 17.0, 95% CI 5.0-60.0, p < 0.001). When considering severe COVID-19 (admission or death) vs. mild or absent COVID-19, institutionalization, neoplasm, dementia and a lower frequency of dopamine agonists were associated with severe COVID-19. In multivariate analysis, only institutionalization [OR 5.17, 95% CI 1.57-17, p = 0.004] and neoplasm [OR 8.0, 95%CI 1.27-49.8, p = 0.027] remained significantly associated. CONCLUSION: In our experience, institutionalization and oncologic comorbidity, rather than PD-related variables, increased the risk of developing COVID-19, and impacted on its severity. These findings suggest that epidemiologic factors and frailty are key factors for COVID-19 morbidity/mortality in PD. Appropriate preventive strategies should be implemented in institutionalized patients to prevent infection and improve prognosis.
Subject(s)
COVID-19 , Parkinson Disease , Aged , Case-Control Studies , Humans , Male , Parkinson Disease/complications , Parkinson Disease/drug therapy , Parkinson Disease/epidemiology , Retrospective Studies , SARS-CoV-2 , Spain/epidemiologyABSTRACT
INTRODUCTION: The main challenge of Parkinson's disease in women of childbearing age is managing symptoms and drugs during pregnancy and breastfeeding. The increase in the age at which women are having children makes it likely that these pregnancies will become more common in future. OBJECTIVES: This study aims to define the clinical characteristics of women of childbearing age with Parkinson's disease and the factors affecting their lives, and to establish a series of guidelines for managing pregnancy in these patients. RESULTS: This consensus document was developed through an exhaustive literature search and a discussion of the available evidence by a group of movement disorder experts from the Spanish Society of Neurology. CONCLUSIONS: Parkinson's disease affects all aspects of sexual and reproductive health in women of childbearing age. Pregnancy should be well planned to minimise teratogenic risk. A multidisciplinary approach should be adopted in the management of these patients in order to take all relevant considerations into account.
Subject(s)
Parkinson Disease , Adolescent , Adult , Consensus , Female , Humans , Neurology , Parkinson Disease/drug therapy , Young AdultABSTRACT
INTRODUCTION: Many diseases associated with hyperkinetic movement disorders manifest in women of childbearing age. It is important to understand the risks of these diseases during pregnancy, and the potential risks of treatment for the fetus. OBJECTIVES: This study aims to define the clinical characteristics and the factors affecting the lives of women of childbearing age with dystonia, chorea, Tourette syndrome, tremor, and restless legs syndrome, and to establish guidelines for management of pregnancy and breastfeeding in these patients. RESULTS: This consensus document was developed through an exhaustive literature search and a discussion of the content by a group of movement disorder experts from the Spanish Society of Neurology. CONCLUSIONS: We must evaluate the risks and benefits of treatment in all women with hyperkinetic movement disorders, whether pre-existing or with onset during pregnancy, and aim to reduce effective doses as much as possible or to administer drugs only when necessary. In hereditary diseases, families should be offered genetic counselling. It is important to recognise movement disorders triggered during pregnancy, such as certain types of chorea and restless legs syndrome.
Subject(s)
Movement Disorders , Parkinson Disease , Adolescent , Adult , Chorea , Dystonia , Female , Humans , Movement Disorders/drug therapy , Parkinson Disease/drug therapy , Restless Legs Syndrome/drug therapy , Tourette Syndrome , Young AdultABSTRACT
INTRODUCTION: Unilateral Gamma Knife™ stereotactic radiosurgery on the ventral-intermediate nucleus of the thalamus is a minimally invasive neurosurgical option for refractory tremor. We describe the experience of Gamma Knife™ thalamotomy (GKT) in patients with essential tremor (ET) and tremor-dominant Parkinson's disease (PD) at our specialised stereotactic neurosurgery unit. METHODS: We reviewed the cases of patients treated with GKT between January 2014 and February 2018 with a minimum of 12 months' follow-up. We analysed clinical and demographic variables, indication, radiation dose, effectiveness (based on subscales of the Fahn-Tolosa-Marin [FTM] scale and the Movement Disorders Society-Unified Parkinson's Disease Rating Scale [MDS-UPDRS] motor score), and adverse events. RESULTS: Thirteen patients were registered, 6 with a diagnosis of tremor-dominant PD, four with refractory ET, and three with ET and PD. Median age was 78 years (range, 62-83), with seven patients aged over 75 years. Four patients were receiving anticoagulants and two had history of stroke. The maximum radiation dose administered was 130 Gy. Mean (standard deviation) follow-up duration was 30.0 (14.5) months. Significant tremor improvement was observed on the FTM subscales: 63.6% at 12 months and 63.5% at the end of follow-up; MDS-UPDRS tremor items showed improvements of 71.3% at 12 months and 60.3% at the end of follow up. Eleven patients reported significant improvements in quality of life, and 3 reported mild and transient adverse effects. CONCLUSIONS: This is the largest series of patients with essential and parkinsonian tremor treated with GKT and followed up in the long term in Spain. GKT can be safe and effective in the long term in patients with refractory tremor, including in elderly patients and those receiving anticoagulants.
ABSTRACT
BACKGROUND AND PURPOSE: Contingent negative variation (CNV) is a negative cortical wave that precedes a pre-cued imperative stimulus requiring a quick motor response. It has been related to motor preparation and anticipatory attention. The aim was to ascertain whether the clinical improvement of functional movement disorders after physiotherapy would be associated with faster reaction times and modulation of CNV. METHODS: Motor performance and CNV were analysed during a pre-cued choice reaction time task with varying cue validity. Twenty-one patients with functional movement disorders and 13 healthy controls at baseline were compared. Patients then underwent physiotherapy. At follow-up after physiotherapy, patients were categorized as clinically improved (responders) or not improved (non-responders) and retested. RESULTS: At baseline, patients did not generate CNV, contrary to controls [mean amplitude (µV) at the end of preparation to move: patients -0.47 (95% CI -1.94, 1.00) versus controls -2.59 (95% CI -4.46, -0.72)]. Responders performed faster after physiotherapy [mean natural logarithm (ln) reaction time (RT) (ms): follow-up 6.112 (95% CI 5.923, 6.301) versus baseline 6.206 (95% CI 6.019, 6.394), P = 0.010], contrary to non-responders. Simultaneously, responders showed a recovery of CNV after physiotherapy [follow-up -1.95 (95% CI -3.49, -0.41) versus baseline -0.19 (95% CI -1.73, 1.35), P < 0.001], contrary to non-responders [follow-up -0.32 (95% CI -1.79, 1.14) versus baseline -0.72 (95% CI -2.19, 0.75), P = 0.381]. CONCLUSIONS: Clinical improvement of functional movement disorders after physiotherapy was associated with faster reaction times and normalization of CNV, which was absent at baseline. These findings suggest that CNV may constitute a useful neurophysiological biomarker related to abnormal attention in functional movement disorders.
Subject(s)
Contingent Negative Variation , Movement Disorders , Adult , Attention , Biomarkers , Electroencephalography , Female , Humans , Male , Middle Aged , Movement , Movement Disorders/diagnosis , Movement Disorders/therapy , Reaction TimeABSTRACT
BACKGROUND: Gating of sensory evoked potentials (SEPs) around the onset of a voluntary movement is a physiological phenomenon with centripetal and central components, and may reflect sensorimotor integration required for normal movement control. OBJECTIVE: Our objective was the investigation of SEP suppression at the onset of movement and the interaction between SEP suppression and vibration of the limb. METHODS: Fourteen patients with primary focal/segmental dystonia and 17 age-matched healthy volunteers were studied. SEPs were elicited after electrical stimulation of the median nerve at the wrist. Electroencephalograms (EEGs) were recorded over the scalp at three sites according to the International 10-20 System (F3, C3 and P3). SEPs were recorded in four conditions: at rest, at the onset of movement (a self-paced abduction movement of the right thumb), both in the absence and in the presence of vibration of the limb. RESULTS: Repeated measures anova revealed that there was a significant main effect of group [F(1, 11.1) = 0.471, P = 0.002]. Post hoc exploration of this effect revealed it to be due to an absence of SEP suppression at movement onset in patients (mean ratio SEP movement onset/rest 1.15 at F3, 1.13 at C3, 1.01 at P3) compared to controls, who had SEP suppression at movement onset (mean ratio SEP movement onset/rest 0.79 at F3, 0.78 at C3, 0.77 at P3). With vibration, SEP suppression reduced in both patients and controls to a similar extent. CONCLUSION: These results demonstrate abnormal SEP suppression at the onset of movement in patients with primary dystonia, and in addition that vibration of the limb reduces SEP suppression in patients and controls.
Subject(s)
Dystonic Disorders/physiopathology , Evoked Potentials, Somatosensory/physiology , Median Nerve/physiopathology , Wrist/physiopathology , Adult , Aged , Electric Stimulation , Electroencephalography , Female , Humans , Male , Middle AgedABSTRACT
BACKGROUND: Beliefs and expectations about symptoms and an abnormal direction of attention towards the body have been proposed as important mechanistic factors in the pathophysiology of functional motor symptoms (FMS). We therefore aimed to evaluate patients' awareness/perception of the presence and severity of their own symptoms before and while watching themselves in a video and to compare this with doctors' assessment of the presence and severity of FMS, based on video evaluation. METHODS: We evaluated 16 patients affected by FMS. Patients were invited to give a "subjective evaluation" of their symptoms. Afterwards, patients were invited to watch a video of themselves and to judge the presence of symptoms in the different body parts and, if so, to rate the severity. Patients' videos were also assessed by a rater with expertise in FMS. RESULTS: Patients judged their symptoms to be more severe on subjective evaluation than when viewing a video of themselves (p = 0.002; t = 3.656). Subjective evaluation of symptom severity by patients was higher than that of raters viewing a video of the patient (p < 0.001, t = 4.860), but there was only a trend towards a difference between video ratings of severity by patients and independent raters (p = 0.017, t = 2.962 with p set at 0.016 according to Bonferroni correction). CONCLUSIONS: Our study shows that patients with FMS tend to overestimate the severity of their symptoms compared independent rating. However, when viewing a video of themselves they rated their symptoms as less severe and closer to those of independent raters.
Subject(s)
Diagnostic Self Evaluation , Motor Disorders/diagnosis , Physician's Role , Severity of Illness Index , Visual Perception/physiology , Adult , Aged , Female , Humans , Male , Middle Aged , Motor Disorders/psychology , Photic Stimulation/methods , Physician's Role/psychology , Video Recording/methods , Young AdultABSTRACT
BACKGROUND AND PURPOSE: Traditionally dystonia has been considered a disorder of basal ganglia dysfunction. However, recent research has advocated a more complex neuroanatomical network. In particular, there is increasing interest in the pathophysiological role of the cerebellum. Patients with cervical and focal hand dystonia have impaired cerebellar associative learning using the paradigm eyeblink conditioning. This is perhaps the most direct evidence to date that the cerebellum is implicated in patients. METHODS: Eleven patients with DYT1 dystonia and five patients with DYT6 dystonia were examined and rates of eyeblink conditioning were compared with age-matched controls. A marker of brainstem excitability, the blink reflex recovery, was also studied in the same groups. RESULTS: Patients with DYT1 and DYT6 dystonia have a normal ability to acquire conditioned responses. Blink reflex recovery was enhanced in DYT1 but this effect was not seen in DYT6. CONCLUSIONS: If the cerebellum is an important driver in DYT1 and DYT6 dystonia our data suggest that there is specific cerebellar dysfunction such that the circuits essential for conditioning function normally. Our data are contrary to observations in focal dystonia and suggest that the cerebellum may have a distinct role in different subsets of dystonia. Evidence of enhanced blink reflex recovery in all patients with dystonia was not found and recent studies calling for the blink recovery reflex to be used as a diagnostic test for dystonic tremor may require further corroboration.
Subject(s)
Blinking/physiology , Cerebellar Diseases/physiopathology , Conditioning, Psychological/physiology , Dystonia Musculorum Deformans/physiopathology , Adult , Aged , Aged, 80 and over , Brain Stem/physiopathology , Electric Stimulation , Electromyography , Female , Humans , Male , Middle Aged , Young AdultABSTRACT
BACKGROUND AND PURPOSE: Functional tics, also called psychogenic tics or pseudo-tics, are difficult to diagnose because of the lack of diagnostic criteria and their clinical similarities to organic tics. The aim of the present study was to report a case series of patients with documented functional tics and to describe their clinical characteristics, risk factors and psychiatric comorbidity. Also clinical tips are suggested which might help the differential diagnosis in clinical practice. METHODS AND RESULTS: Eleven patients (mean age at onset 37.2, SD 13.5; three females) were included with a documented or clinically established diagnosis of functional tics, according to consultant neurologists who have specific expertise in functional movement disorders or in tic disorders. Adult onset, absent family history of tics, inability to suppress the movements, lack of premonitory sensations, absence of pali-, echo- and copro-phenomena, presence of blocking tics, the lack of the typical rostrocaudal tic distribution and the coexistence of other functional movement disorders were common in our patients. CONCLUSIONS: Our data suggest that functional tics can be differentiated from organic tics on clinical grounds, although it is also accepted that this distinction can be difficult in certain cases. Clinical clues from history and examination described here might help to identify patients with functional tics.
Subject(s)
Tic Disorders/diagnosis , Adult , Female , Humans , Male , Middle Aged , Tic Disorders/etiology , Tic Disorders/physiopathologyABSTRACT
BACKGROUND: Primary cervical dystonia is the most common form of adult-onset focal dystonia. Although most frequently sporadic, 15-20% of patients report a positive family history, suggesting a possible genetic cause. Head tremor is often present in patients with cervical dystonia and may be a prominent symptom. OBJECTIVE: To describe the clinical characteristics of patients with tremulous cervical dystonia. METHODS: Patients with primary cervical dystonia attending our botulinum toxin clinic were assessed with an interview and neurological examination and their notes reviewed. Patients were classified as having either tremulous or non-tremulous cervical dystonia, according to the presence or absence of head tremor on examination. Clinical and demographic data were compared between groups. RESULTS: From 273 patients included (190 females, 83 males), 125 (46%) were classified as tremulous and 148 (54%) as non-tremulous. Tremulous patients were more likely to have a segmental distribution (61% vs. 25%), often involving the arms (48%), and had more frequently associated arm tremor (55% vs. 10%). A positive family history of dystonia and/or tremor was more frequent in tremulous patients (50% vs. 18%). CONCLUSIONS: Patients with cervical dystonia with associated head tremor are more likely to have a segmental distribution (with frequent arm involvement), associated arm tremor and a positive family history, suggesting a genetic etiology in this subgroup of patients.
Subject(s)
Family Health , Torticollis/complications , Torticollis/genetics , Tremor/etiology , Tremor/genetics , Aged , Anti-Dyskinesia Agents/therapeutic use , Botulinum Toxins/therapeutic use , Cohort Studies , Female , Humans , Male , Middle Aged , Torticollis/drug therapy , Tremor/drug therapyABSTRACT
Adaptation of a rapid ballistic movement requires that commands for the next movement are updated on the basis of sensory error signals from the current movement. Previous experiments, mostly using visual feedback, have demonstrated that adaptation is highly sensitive to the timing of feedback and can be substantially impaired by delays of 100 ms or so. Here, we use the phenomenon of surround inhibition (SI) to explore the consequences of somatosensory feedback delay in a task requiring participants to flex the index finger without generating any electromyographical (EMG) activity in other fingers. Participants were requested to perform brief isolated flexion movements of the index finger. After a short period of practice, SI in the distant abductor digiti minimi (ADM) muscle was quantified by measuring the amplitude of EMG responses evoked by a standard pulse of transcranial magnetic stimulation to the contralateral motor cortex at the onset of flexion. SI indicates that the response during flexion was smaller than the response at rest. After this, two training blocks were performed in which the ADM muscle was vibrated (80 Hz, 100 ms) either at the onset (VIB(onset)) of finger flexion or with a delay of 100 ms (VIB(100)). SI was reassessed after training. SI measured after VIB(onset) training was transiently more effective than at baseline. In contrast, SI was unchanged compared to baseline after VIB(100). The present study demonstrates that SI can be modified by experience. The timing of the sensory stimulation was found to be critical for the modification of SI, suggesting that only sensory signals closely related to the movement onset can induce adaptive changes, presumably through a feed-forward process.
Subject(s)
Adaptation, Physiological/physiology , Biofeedback, Psychology/physiology , Movement/physiology , Neural Inhibition/physiology , Analysis of Variance , Electromyography , Evoked Potentials, Motor/physiology , Female , Humans , Male , Muscle, Skeletal/physiology , Reaction Time , Time Factors , Transcranial Magnetic Stimulation , VibrationABSTRACT
Functional neurological disorders are common, disabling and often difficult to treat. There is little consensus on the best approach to management. Multidisciplinary inpatient approaches are employed in some centres for patients with severe refractory symptoms, but their efficacy and, in particular, long-term outcomes are uncertain. We conducted a study using questionnaires completed retrospectively by patients treated at a specialised multidisciplinary inpatient programme at the National Hospital for Neurology and Neurosurgery. Consecutive patients with functional motor symptoms admitted to this centre between 2006 and 2008 were invited to participate. Questionnaires were sent at least 2 years after discharge. We contacted 32 patients, and 26 responded. The majority had symptoms for at least 3 years prior to admission; 58 % of patients reported benefit from the programme on discharge. This self-reported benefit to symptoms and function was after a 2-year follow-up period in the majority of patients, but return to work or cessation of health-related financial benefits was uncommon even in those who improved. Seventy-four percent of those questioned stated they would recommend the programme to others with similar symptoms. Attribution of symptoms to stress or emotional state was correlated with favourable outcome. Our data suggest that multidisciplinary inpatient treatment for patients with refractory functional motor symptoms provides self-reported benefit in the long-term. Prospective analysis of such interventions and the determinants of benefit need assessment in order to improve the service and target treatment to patients most likely to benefit.
Subject(s)
Behavior Therapy/methods , Disabled Persons/rehabilitation , Inpatients , Movement Disorders/etiology , Movement Disorders/rehabilitation , Nervous System Diseases/complications , Adult , Female , Humans , Longitudinal Studies , Male , Middle Aged , Mood Disorders/etiology , Retrospective Studies , Surveys and QuestionnairesABSTRACT
INTRODUCTION: Spinal cord involvement is a rare presentation of grade II astrocytomas. Nevertheless, differentiation from inflammatory demyelinating diseases of the central nervous system can be challenging in some clinical situations. A patient with an optic-spinal syndrome due to a fibrillary astrocytoma is described. CASE REPORT: A 32 years-old man was admitted to the hospital because of a subacute spinal cord syndrome. Brain MRI showed no abnormalities, and spinal MRI disclosed a cervical cord lesion suggestive of myelitis. Cerebrospinal fluid analysis revealed oligoclonal bands. Clinical improvement was observed after corticosteroid treatment. Three months later, the patient presented with binocular vision loss. A bilateral retrobulbar optic neuritis was suspected, and corticosteroid therapy was administered again. A new MRI with spectroscopy revealed an infiltrative lesion involving the right frontal lobe, optic chiasm, internal capsule, brainstem and cervical spinal cord, which was suggestive of low-grade astrocytoma. Brain biopsy confirmed the diagnosis of diffuse fibrillary astrocytoma. CONCLUSION: Differential diagnosis between inflammatory and neoplastic lesions of the central nervous system requires close clinical-radiological follow-up. In this clinical situation, treatment response to corticosteroids and presence of oligoclonal bands in the cerebrospinal fluid may be not necessarily indicative of an inflammatory demyelinating process. Brain biopsy is often necessary for a definite diagnosis.