The Development of the Social Functioning Scale for Patients with Parkinson's Disease.

BACKGROUND: Social functioning is crucial for the determinants of Parkinson's disease (PD) with dementia; however, there is no social functioning scale applicable to PD. OBJECTIVE: This study aimed to develop a social functioning scale specific to PD (PDSFS) and provide a cut-off score to improve diagnosis accuracy. METHODS: The items were developed through literature, interview patients, and PD expertise. After the pilot study, one hundred fifty-seven patients and 74 healthy participants were enrolled and completed the Mini-Mental State Examination, Clock Drawing Test, Activities of Daily Living, Neuropsychiatric Inventory, Adaptive Behavior Assessment System-Second Edition (ABAS-II) and part III of the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS). RESULTS: The final PDSFS has 23 items. The exploratory factor analysis revealed three factors, including "Family Life, Hobbies and Self-Care", "Interpersonal Relationship and Recreational Leisure", and "Social Bond". The internal consistency coefficient was 0.883, and the test-retest reliability was 0.774, respectively. The total score of the PDSFS was significantly related to the total score of ABAS-II (r = 0.609, p < 0.001), and was not correlated with the third part of MDS-UPDRS (p = 0.736). A significant intergroup difference was found (p < 0.001), and the healthy controls had the highest PDSFS score, followed by non-demented PD and PD dementia. The optimal cut-off score for PD patients with dementia was 39 (sensitivity: 0.735; specificity: 0.857). CONCLUSIONS: PDSFS is a practical and psychometrically sound tool to access the social functioning of the PD population.

Amyotrophic lateral sclerosis presenting as the temporomandibular disorder: A case report and literature review.

BACKGROUND: Spasticity and pain in the masticatory muscles or mouth opening limitation have been reported as early signs and symptoms of amyotrophic lateral sclerosis (ALS). These signs and symptoms are also frequently seen in, and thus mistaken for, temporomandibular disorders (TMD). CLINICAL PRESENTATION: The authors report a case of ALS initially presenting with signs and symptoms of TMD. The TMD was followed by dysarthria of insidious onset, leading to the diagnosis of ALS. This case highlights the importance of considering TMD as a potential early form of presentation of ALS, requiring multidisciplinary treatment, especially by dental professionals. CONCLUSION: A review of the literature was conducted to elucidate the oral and facial signs and symptoms of ALS and to identify ways of improving the quality of life of patients through a multidisciplinary approach.

Determinants of generic and specific health-related quality of life in patients with Parkinson's disease.

OBJECTIVES: Generic and disease-specific health-related quality of life (HRQoL) instruments may reflect different aspects of lives in patients with Parkinson's disease (PD) and thus be associated with different determinants. We used the same cluster of predictors for the generic and disease-specific HRQoL instruments to examine and compare the determinants of HRQoL. METHOD: HRQoL was measured in 92 patients with PD by the 36-item Short-Form Health Survey (SF-36) and the 39-item Parkinson's Disease Questionnaire (PDQ-39). The predictors included demographic and disease characteristics, and motor and non-motor symptoms. Multiple regression analyses were used to identify HRQoL determinants. RESULTS: Depressive symptoms and motor difficulties of daily living were the first two significant determinants for both instruments. The other significant determinant for the SF-36 was fatigue and non-motor difficulties of daily living, and for the PDQ-39 was motor signs of PD. CONCLUSIONS: The results suggest the importance of the evaluation and intervention focused on depressive symptoms and motor difficulties of daily living in patients with PD. In addition, the SF-36 seems more related to non-motor symptoms, while the PDQ-39 appears more associated with motor symptoms. This information is important for understanding results from these two instruments and for choosing which to use.

Responsiveness of the short-form health survey and the Parkinson's disease questionnaire in patients with Parkinson's disease.

BACKGROUND: The responsiveness of a measurement instrument is important for understanding its ability to detect changes in the progression of a disease. We examined and compared the internal and external responsiveness of the 36-item Short-Form Health Survey (SF-36) and the 39-item Parkinson's Disease Questionnaire (PDQ-39) in patients with Parkinson's Disease (PD). METHODS: Seventy-four patients with PD were evaluated using the SF-36 and PDQ-39 at baseline and again after one year. In addition, their motor signs, motor difficulties of daily living, and depressive symptoms were assessed as external criteria. The internal responsiveness was examined using effect size, standardized response mean, and the Wilcoxon signed rank test. The external responsiveness was examined using receiver operating characteristic curves, correlation analyses, and regression models. RESULTS: Both instruments were partially sensitive to changes during the 1-year follow-up and able to discriminate between patients with improved versus deteriorated motor signs. In addition, both were similarly responsive to changes in the motor difficulties of daily living; the SF-36 appeared to be more sensitive than the PDQ-39 to changes in depressive symptoms. CONCLUSIONS: The SF-36 and the PDQ-39 were acceptably internally and externally responsive during the 1-year follow-up.

Reversible pseudoathetosis and sensory ataxic gait caused by cervical spondylotic myelopathy.

Proprioceptive deafferentation of spinal cord origin can cause pseudoathetosis, sensory ataxic gait, or both. The co-existence of pseudoathetosis and sensory ataxic gait caused by a surgically treatable condition of the spinal cord has been rarely reported. An 80-year-old man with cervical spondylotic myelopathy presented with severe sensory ataxic gait which confined him to a wheelchair. He also had poor control of his hands due to the pseudoathetoid movements of the fingers, which prevented him from sustaining constant muscle contraction. He underwent C3-4 and C4-5 anterior discectomies and anterior fusion. His neurological deficits gradually improved after the decompressive surgery. About 7months postoperatively, he was totally independent in activities of daily living and needed no mobility aid. This case highlights the clinical importance of recognizing a surgically treatable and reversible condition of the spinal cord that causes pseudoathetosis and sensory ataxic gait.

Parkinsonism or Other Movement Disorders Presenting as Stroke Mimics.

PURPOSE: Patients with parkinsonism or other movement disorders may visit the emergency department due to acute deterioration of neurological status or consciousness disturbance. Under such circumstances, patients may be misdiagnosed as having a hyperacute stroke, i.e. stroke mimic. The purpose of the present study was to explore the clinical features and consequences of patients with parkinsonism or other movement disorders presenting as stroke mimics with activation of a stroke code. METHODS: In this retrospective case-series study, we reviewed the charts and stroke code registry data in two stroke centers with high volume of stroke codes and thrombolytic therapy in the Southern Taiwan. RESULTS: We found seven male patients (67.0 ± 12.8 years old): one with focal myoclonus, one with focal dystonia, and the other five with parkinsonism. The chief problems for emergency department visit included acute consciousness disturbance in one patient and motor weakness in other six patients. Five of the six patients with motor weakness complained unilateral symptoms. Six patients were evaluated by neurology residents (five by second-year residents, one by a third-year resident) and one by a board-certified neurologist, while a misdiagnosis of a stroke was made in three patients. All patients experienced neurological improvement when follow-up. One patient who received intravenous thrombolytic therapy had no intracranial hemorrhagic complications. CONCLUSION: Although rare, parkinsonism or other movement disorders may present as a stroke mimic with activation of a stroke code. Consulting neurologists should clarify the etiology for those patients with acute consciousness disturbance or motor weakness and avoid unnecessary thrombolysis. Key Words: Parkinson disease, parkinsonism, movement disorders, stroke code, thrombolysis.

Motor vehicle accidents and injuries in patients with idiopathic blepharospasm.

BACKGROUND: Blepharospasm can cause transient functional blindness that may cause catastrophic traffic accidents. METHODS: Sixty-six patients in southern Taiwan with idiopathic blepharospasm were enrolled. The incidence of and injuries from traffic accidents from the onset of blepharospasm symptoms to the first injection of botulinum toxin were analyzed. Data were collected from medical records and face-to-face interviews with patients and their families. RESULTS: Twenty-six patients (39.4%) had traffic accidents (21 motorcycle; 5 car). There were 5 incapacitating motorcycle injuries: 1 cervical spine injury with quadriparesis, 1 blunt abdominal injury with internal bleeding, 2 broken limbs, and 1 ligament rupture; 1 incapacitating car injury: broken limb of other person; and 11 non-incapacitating motorcycle injuries (abrasions, bruises, and minor lacerations). Nine patients were uninjured. CONCLUSIONS: Blepharospasm caused incapacitating injuries for motorcyclists themselves and another person in a car accident. Patients with untreated blepharospasm should avoid riding motorcycles and driving cars.

Increasing speed to improve arm movement and standing postural control in Parkinson's disease patients when catching virtual moving balls.

Research has shown that moving targets help Parkinson's disease (PD) patients improve their arm movement while sitting. We examined whether increasing the speed of a moving ball would also improve standing postural control in PD patients during a virtual reality (VR) ball-catching task. Twenty-one PD patients and 21 controls bilaterally reached to catch slow-moving and then fast-moving virtual balls while standing. A projection-based VR system connected to a motion-tracking system and a force platform was used. Dependent measures included the kinematics of arm movement (movement time, peak velocity), duration of anticipatory postural adjustments (APA), and center of pressure (COP) movement (movement time, maximum amplitude, and average velocity). When catching a fast ball, both PD and control groups made arm movements with shorter movement time and higher peak velocity, longer APA, as well as COP movements with shorter movement time and smaller amplitude than when catching a slow ball. The change in performance from slow- to fast-ball conditions was not different between the PD and control groups. The results suggest that raising the speed of virtual moving targets should increase the speed of arm and COP movements for PD patients. Therapists, however, should also be aware that a fast virtual moving target causes the patient to confine the COP excursion to a smaller amplitude. Future research should examine the effect of other task parameters (e.g., target distance, direction) on COP movement and examine the long-term effect of VR training.

Progressive micrographia shown in horizontal, but not vertical, writing in Parkinson's disease.

All published studies on micrographia, a diminution of letter size, examine handwriting in the horizontal direction. Writing horizontally typically requires increased wrist extension as handwriting progresses from left to right. Chinese characters, however, can be written not only horizontally from left to right, but also vertically from top to bottom. We examined the effect of handwriting direction on character size and stroke length. Fifteen participants with Parkinson's disease (PD) and 15 age-matched controls wrote the same Chinese characters both horizontally and vertically. Handwriting performance was recorded with a digitizing tablet, and a custom-written computer program was used to provide objective data about character size and stroke length. The PD group had a linear decrease in overall character size and horizontal strokes along the writing sequence in the horizontal direction, but not in the vertical direction. The controls had shorter horizontal strokes in the horizontal than the vertical direction, but there was no progressive shortening of stroke length along the writing sequence. The results suggest that traditionally reported progressive micrographia in horizontal writing may not be generalizable to vertical writing. The observed decrease of handwriting size in the horizontal direction suggests that micrographia in PD may be associated with wrist extension. For clinical implications, patients may mitigate their micrographia by changing handwriting direction.

SPECT study of the nigrostriatal dopaminergic system in Huntington's disease.

BACKGROUND AND PURPOSE: The pathological process of Huntington's disease (HD) preferentially targets spiny neurons in the striatum, with later involvement of the substantia nigra and other structures. The purpose of this study is to investigate the nigrostriatal dopaminergic system in a genetically confirmed HD family. METHODS: We used single photon emission computed tomography (SPECT) with the radiotracers [(99m) Tc]TRODAT-1 and [123I]IBZM to study the binding potentials of dopamine transporter (DAT) and dopamine D2 receptors in the striatum of 3 symptomatic HD patients, 1 mutation-negative member of the HD family, and 7 healthy controls. Specific binding potentials were calculated as (striatum-occipital lobe)/occipital lobe. RESULTS: Reduced binding potential of striatal dopamine D2 receptors was found in the 3 symptomatic HD patients. The DAT binding potential was reduced in 1 symptomatic HD patient. We also found that the more severe the clinical status, the lower the DAT and D2 receptor binding potentials, and the larger the bicaudate ratio. CONCLUSIONS: We showed that the postsynaptic part of the nigrostriatal pathway was involved. The presynaptic part is usually not affected but could occur in very advanced cases. Our findings suggest that SPECT imaging of D2 receptors is useful for diagnosing and monitoring HD.

Demographic and clinical features of patients with blepharospasm in southern Taiwan: a university hospital-based study.

PURPOSE: Blepharospasm is a common focal dystonia. Severe blepharospasm has a disabling impact on work and everyday activities and may cause social embarrassment and catastrophic traffic accidents.This retrospective case-series study explored the demographic and clinical features and also the impact of blepharospasm on patients in southern Taiwan, where the climate is hot and humid and motorcycles are a popular mode of transportation. METHODS: One hundred eleven patients with essential blepharospasm who had been given botulinum toxin type A injections at a university hospital were enrolled. Data were collected from medical records and face-to-face interviews with the patients and their families. RESULTS: The mean age of onset was 58 years. The female/male ratio was 2.6: 1. Eighty-one percent of our patients had seen an ophthalmologist at the beginning of their condition. Photophobia, sleep benefit,and diurnal change of clinical symptoms were present in over 80% of the patients. The initial diagnostic accuracy was 37% for ophthalmologists and 44% for neurologists. Myasthenia gravis caused most confusion in the differential diagnosis. Eighteen percent of the patients had been involved in motorcycle and car accidents. Regular botulinum toxin type A injections improved both eyelid spasm and subjective ocular symptoms in most patients. CONCLUSION: Blepharospasm is under-recognized, and its differentiation from myasthenia gravis needs to be improved. Patients with blepharospasm are advised to receive regular botulinum toxin type A injections and to avoid riding motorcycles and driving cars.

Trunk-arm coordination in reaching for moving targets in people with Parkinson's disease: comparison between virtual and physical reality.

We used a trunk-assisted prehension task to examine the effect of task (reaching for stationary vs. moving targets) and environmental constraints (virtual reality [VR] vs. physical reality) on the temporal control of trunk and arm motions in people with Parkinson's disease (PD). Twenty-four participants with PD and 24 age-matched controls reached for and grasped a ball that was either stationary or moving along a ramp 120% of arm length away. In a similar VR task, participants reached for a virtual ball that was either stationary or moving. Movement speed was measured as trunk and arm movement times (MTs); trunk-arm coordination was measured as onset interval and offset interval between trunk and arm motions, as well as a summarized index-desynchrony score. In both VR and physical reality, the PD group had longer trunk and arm MTs than the control group when reaching for stationary balls (p<.001). When reaching for moving balls in VR and physical reality, however, the PD group had lower trunk and arm MTs, onset intervals, and desynchrony scores (p<.001). For the PD group, VR induced shorter trunk MTs, shorter offset intervals, and lower desynchrony scores than did physical reality when reaching for moving balls (p<.001). These findings suggest that using real moving targets in trunk-assisted prehension tasks improves the speed and synchronization of trunk and arm motions in people with PD, and that using virtual moving targets may induce a movement termination strategy different from that used in physical reality.

Olanzapine treatment for tics in an adult woman with severe tourette syndrome.

PURPOSE: Olanzapine had been reported to be effective in the control of tics in a few adult female patients who had a short follow-up period. The author reports the successful outcome of long-term olanzapine treatment in an adult woman with severe Tourette syndrome. CASE REPORT: A 33-year-old woman who had severe motor and vocal tics (Modified Rush Videotape Rating Scale: 17/20) showed an excellent response to olanzapine 10 mg/day within 2 months. Her tic symptoms were well controlled with gradual reduction of her dose of olanzapine to 2.5 mg/day during the following 8 years. She was symptom-free without medications in the past 2 years. In addition, she had a normal menstrual cycle and became pregnant during the period of olanzapine treatment. CONCLUSION: Olanzapine may be the drug of first choice for treating severe Tourette syndrome in pubescent female adolescents and young women who wish to have children.

Outcome of acute ischemic stroke in very elderly patients: is intravenous thrombolysis beneficial?

BACKGROUND/AIMS: Intravenous tissue plasminogen activator (tPA) treatment is recommended in acute stroke within 3 h of onset; however, the benefit of its use in the elderly remains uncertain. We assessed the safety and efficacy of tPA treatment in elderly patients. METHODS: We recruited 97 elderly Chinese patients aged ≥80 years with cerebral ischemia presenting within 3 h of onset. Favorable outcomes were defined as discharge to home and modified Rankin Scale (mRS) ≤2 at discharge. RESULTS: For moderate to severe patients (NIHSS ≥6), the baseline characteristics between the tPA (n = 30) and non-tPA (n = 41) group were not different. The proportion of patients discharged home was 56.7 and 61%, respectively (p = 0.72). For patients with baseline mRS ≤2, the frequency of discharged mRS ≤2 was not different (27.3% of the tPA group and 26.9% of the non-tPA group; p = 1.00). Symptomatic intracranial hemorrhage was 6.7 and 2.4%, respectively (p = 0.31). For minor stroke patients (NIHSS ≤5), tPA was not considered and the outcome of those discharged home and mRS ≤2 was 73 and 88%, respectively. CONCLUSION: Elderly patients can be treated safely with intravenous tPA, whereas our data did not support routine thrombolysis. Further randomized trials in the elderly are encouraged.

Comparison of virtual reality versus physical reality on movement characteristics of persons with Parkinson's disease: effects of moving targets.

OBJECTIVE: To compare the performance of reaching for stationary and moving targets in virtual reality (VR) and physical reality in persons with Parkinson's disease (PD). DESIGN: A repeated-measures design in which all participants reached in physical reality and VR under 5 conditions: 1 stationary ball condition and 4 conditions with the ball moving at different speeds. SETTING: University research laboratory. PARTICIPANTS: Persons with idiopathic PD (n=29) and age-matched controls (n=25). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Success rates and kinematics of arm movement (movement time, amplitude of peak velocity, and percentage of movement time for acceleration phase). RESULTS: In both VR and physical reality, the PD group had longer movement time (P<.001) and lower peak velocity (P<.001) than the controls when reaching for stationary balls. When moving targets were provided, the PD group improved more than the controls did in movement time (P<.001) and peak velocity (P<.001), and reached a performance level similar to that of the controls. Except for the fastest moving ball condition (0.5-s target viewing time), which elicited worse performance in VR than in physical reality, most cueing conditions in VR elicited performance generally similar to those in physical reality. CONCLUSIONS: Although slower than the controls when reaching for stationary balls, persons with PD increased movement speed in response to fast moving balls in both VR and physical reality. This suggests that with an appropriate choice of cueing speed, VR is a promising tool for providing visual motion stimuli to improve movement speed in persons with PD. More research on the long-term effect of this type of VR training program is needed.

Effects of virtual reality training on functional reaching movements in people with Parkinson's disease: a randomized controlled pilot trial.

OBJECTIVE: To investigate whether practising reaching for virtual moving targets would improve motor performance in people with Parkinson's disease. DESIGN: Randomized pretest-posttest control group design. SETTING: A virtual reality laboratory in a university setting. PARTICIPANTS: Thirty-three adults with Parkinson's disease. INTERVENTIONS: The virtual reality training required 60 trials of reaching for fast-moving virtual balls with the dominant hand. The control group had 60 practice trials turning pegs with their non-dominant hand. MAIN OUTCOME MEASURES: Pretest and posttest required reaching with the dominant hand to grasp real stationary balls and balls moving at different speeds down a ramp. Success rates and kinematic data (movement time, peak velocity and percentage of movement time for acceleration phase) from pretest and posttest were recorded to determine the immediate transfer effects. RESULTS: Compared with the control group, the virtual reality training group became faster (F = 9.08, P = 0.005) and more forceful (F = 9.36, P = 0.005) when reaching for real stationary balls. However, there was no significant difference in success rate or movement kinematics between the two groups when reaching for real moving balls. CONCLUSION: A short virtual reality training programme improved the movement speed of discrete aiming tasks when participants reached for real stationary objects. However, the transfer effect was minimal when reaching for real moving objects.

The effect of eating utensil weight on functional arm movement in people with Parkinson's disease: a controlled clinical trial.

OBJECTIVE: To investigate the effect of eating utensil weight on kinematic performance in people with Parkinson's disease. DESIGN: A counterbalanced repeated-measures design. SETTING: A motor control laboratory in a university setting. SUBJECTS: Eighteen adults with Parkinson's disease and 18 age-matched controls. EXPERIMENTAL CONDITIONS: Each participant performed a food transfer task using spoons of three different weights: lightweight (35 g), control (85 g) and weighted (135 g). Kinematic variables of arm movement were derived and compared between conditions. MAIN MEASURES: Kinematic variables of arm movement, including movement time, peak velocity and number of movement units. RESULTS: Utensil weights significantly affected the movement kinematicsof all participants. Both groups had fewer movement units in the lightweight condition (Parkinson's disease group: 22.18, controls: 19.89) than in the weighted condition (Parkinson's disease group: 22.68, controls: 21.36), suggesting smoother movement in the former condition. In addition, both groups had higher peak velocity in the lightweight than in the weighted condition. CONCLUSIONS: Our findings suggest that a lightweight utensil may facilitate smoother and higher-velocity arm movement than a weighted one in people with Parkinson's disease.

[The borderland between epilepsy and movement disorders].

Epileptic seizures presenting as motor phenomena without concomitant conscious change may be confused with one of the paroxysmal movement disorders. Conversely, the attack of paroxysmal movement disorders may be thought to be epileptic due to a number of factors, including its sudden, unpredictable, and transient nature, its response to anticonvulsants, and the premonitory sensations preceding attacks. The distinction between epilepsy and movement disorders is further confused by the reports that these two conditions frequently occur in the same families or even in the same patients. Recent studies show that a few epilepsy and paroxysmal movement disorders are "channelopathies", indicating that they may share some common pathophysiology and a possible "overlap". A good quality of history, a trial to reproduce the motor phenomena, the application of video-EEG, polysomnography, and other electrophysiological recordings, together with regular follow-up are important for differentiating these two conditions.

The effects of two different auditory stimuli on functional arm movement in persons with Parkinson's disease: a dual-task paradigm.

OBJECTIVE: To examine, in a dual-task paradigm, the effect of auditory stimuli on people with Parkinson's disease. DESIGN: A counterbalanced repeated-measures design. SETTING: A motor control laboratory in a university setting. SUBJECTS: Twenty individuals with Parkinson's disease. EXPERIMENTAL CONDITIONS: Each participant did two experiments (marching music experiment and weather forecast experiment). In each experiment, the participant performed an upper extremity functional task as the primary task and listened to an auditory stimulus (marching music or weather forecast) as the concurrent task. Each experiment had three conditions: listening to the auditory stimulus, ignoring the auditory stimulus and no auditory stimulus. MAIN MEASURES: Kinematic variables of arm movement, including movement time, peak velocity, deceleration time and number of movement units. RESULTS: We found that performances of the participants were similar across the three conditions for the marching music experiment, but were significantly different for the weather forecast experiment. The comparison of condition effects between the two experiments indicated that the effect of weather forecast was (marginally) significantly greater than that of marching music. CONCLUSIONS: The results suggest that the type of auditory stimulus is important to the degree of interference with upper extremity performance in people with Parkinson's disease. Auditory stimuli that require semantic processing (e.g. weather forecast) may distract attention from the primary task, and thus cause a decline in performance.