The associations between fatigue, apathy, and depression in Parkinson's disease.

OBJECTIVES: Fatigue and apathy are two of the most common and most disabling non-motor symptoms of Parkinson's disease (PD). They have a high coincidence and can often be confused; moreover, their relationship is not fully understood. The aim of our study was to describe the coincidence of apathy with different fatigue domains in the presence/absence of depression and to separately describe the associations of different aspects of primary and secondary fatigue with apathy and other clinical and disease-related factors. MATERIALS AND METHODS: A total of 151 non-demented patients with PD were examined using the Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Starkstein Apathy Scale, Multidimensional Fatigue Inventory (MFI), Beck Depression Inventory-II, and Epworth Sleepiness Scale. RESULTS: The prevalence and severity of fatigue and apathy were significantly higher in depressed PD patients. However, our results show that depression, fatigue, and apathy can be clearly distinguished in PD. Apathy was associated with the MFI's-reduced motivation domain in both depressed and non-depressed patients. However, apathy was associated with mental fatigue aspects only in non-depressed patients, and it was not related to the physical aspects of fatigue in any of the studied groups. CONCLUSIONS: Although the pathophysiology of fatigue and apathy in PD is clearly multifactorial, in a proportion of PD patients, these symptoms are associated with depression, dopaminergic depletion in the mesocorticolimbic structures, and disruption of the prefrontal cortex-basal ganglia axis. Therefore, in some PD patients, adequate management of depression and optimal dopaminergic medication may improve both fatigue and apathy.

The clinical utility of botulinum toxin injections targeted at the motor endplate zone in cervical dystonia.

BACKGROUND AND PURPOSE: Cervical dystonia (CD) patients usually receive repeated botulinum neurotoxin (BoNT) injections. The aims of this study were to evaluate the feasibility of motor endplate zone (MEZ) detection of relevant cervical muscles in CD patients receiving chronic BoNT treatment and to compare the treatment effect of half-dosed, endplate-targeted injections to standard BoNT injections. METHODS: In study 1, high-density surface electromyography (HD-sEMG) was recorded from the sternocleidomastoid (SCM) and splenius capitis (SC) muscles in 18 CD patients with ongoing BoNT treatment, by which the location of the MEZ was determined. In study 2, nine additional patients with rotational-type CD participated in a treatment effect study where they received either half of their regular BoNT dose through endplate-targeted injections or their normal BoNT dose through standard injections (crossover design). Dystonia severity was recorded before and 4 weeks after each treatment session (Toronto Western Spasmodic Torticollis Rating Scale severity subscore). RESULTS: In the SCM muscle the MEZ was located at the lower border of the superior third part of the muscle, and in the SC muscle at half muscle length. Endplate-targeted, half-dosed BoNT injection resulted in a similar treatment effect to injecting the full dose in the standard technique. CONCLUSIONS: Half-dosed, endplate-targeted BoNT injections lead to a similar treatment effect to the standard BoNT injection protocol. MEZ detection confronts the clinician with some technical challenges, such as the ability of accurate and technically optimal placement of the electrode grid and correct interpretation of the HD-sEMG signal.

Localised task-dependent motor-unit recruitment in the masseter.

Localised motor-unit (MU) recruitment in the masseter was analysed in this study. We investigated whether differential activation behaviour, which has already been reported for distant masseter regions, can also be detected in small muscle subvolumes at the level of single MUs. Two bipolar fine-wire electrodes and an intra-oral 3D bite-force transmitter were used to record intra-muscular electromyograms (EMG) resulting from controlled bite-forces of 10 healthy human subjects (mean age 24.1 ± 1.2 years). Two-hundred and seventeen decomposed MUs were organised into localised MU task groups with different (P < 0.001) force-direction-specific behaviour. Proportions of MUs involved in one, two, three or four examined tasks were 46%, 31%, 18% and 5%, respectively. This study provides evidence of the ability of the neuromuscular system to modify the mechanical output of small masseter subvolumes by differential control of adjacent MUs belonging to distinct task groups. Localised differential activation behaviour of the masseter may be the crucial factor enabling highly flexible and efficient adjustment of the muscle activity in response to complex local biomechanical needs, for example, continually varying bite-forces during the demanding masticatory process.

A survey of the outcome of prophylaxis, on-demand treatment or combined treatment in 18-35-year old men with severe haemophilia in six countries.

A number of studies have been published on the benefits of prophylactic treatment in adults with haemophilia. However, in many countries, it is considered as optional due to financial constraints. This survey was carried out to examine the long-term effects of prophylaxis and the continuing benefit of the treatment into adulthood. Self-assessed health-related data and the EQ-5D questionnaire measuring health utility were collected from 124 men (26.9 ± 4.6 years) from Canada (N = 40), France (N = 14), Ireland (N = 17), the Netherlands (N = 16), Poland (N = 24) and the UK (N = 13). The respondents were split into four groups: On-Demand, <50% life on prophylaxis, ≥ 50% life on prophylaxis, Prophylaxis. Overall, long-term prophylaxis results in lower presence of target joints (P ≤ 0.001), occurrence of serious bleeding episodes (P ≤ 0.05), recurring bleeding episodes (P ≤ 0.01) and requirement for surgical procedures (P ≤ 0.05). Furthermore, health utility (P ≤ 0.01) in the On-demand group was significantly lower (P ≤ 0.01) compared to the ≥ 50% life on prophylaxis and the Prophylaxis group. No significant differences between countries were found except between the Netherlands and Poland, with Poland showing the lowest health utility (P ≤ 0.01) and the most problems with mobility (P ≤ 0.05) and pain/discomfort (P ≤ 0.001). The Netherlands showed the highest health utility (0.915) followed by Canada (0.791), Ireland (0.786), UK (0.768), France (0.687) and Poland (0.629). The results demonstrate consistently higher quality of life of individuals who are on long-term prophylactic treatment when compared to on-demand treatment or intermittent prophylaxis and on -demand treatment.

Long-term results of the SOFTGRIP trial: TIPP versus ProGrip Lichtenstein's inguinal hernia repair.

PURPOSE: In preventing Chronic Postoperative Inguinal Pain (CPIP) after inguinal herniorrhaphy, mesh position and mesh fixation seem important factors. The SOFTGRIP trial compared the TransInguinal PrePeritoneal (TIPP) repair to Polysoft mesh, to the Open anterior repair (Lichtenstein) using the self-gripping ProGrip mesh. Since CPIP might resolve and recurrence rate increase, this study reports the SOFTGRIP trial's long-term results (with a minimal follow-up of 5 years). METHODS: All patients initially randomized in the SOFTGRIP trial were contacted if not deceased. Patients were invited for an interview and physical examination. The procedures and methodology of this randomized clinical trial have been published together with the short-term results. The main outcomes for this long-term follow-up study were chronic pain, recurrences, re-operations and numbness. RESULTS: A total of 193 patients (81.4% of the initially randomized patients) were included for long-term follow-up analyses, 96 after TIPP, 97 after ProGrip Lichtenstein. After a median follow-up of 74 months (range 60-80) there were no significant differences between the two groups. Overall, chronic pain drastically decreased. Fourteen patients reported CPIP at long-term follow-up (overall 7.3%, 7 after TIPP and 7 after ProGrip Lichtenstein, any form, frequency and intensity of pain included). Recurrence rate increased from 2.6% (n = 6) at one-year follow-up, to 8.3% (n = 16) at 5-year's follow-up. CONCLUSION: The SOFTGRIP trial´s long-term outcomes show that after both TIPP and ProGrip Lichtenstein, recurrence rate increases and CPIP mostly disappears. These findings aid in better informing patients on the benefits and harms of inguinal hernia repair. The findings of accumulating recurrences and fading of chronic pain, confirms the need for long-term follow-up studies. High-quality long-term data on TIPP, ProGrip Lichtenstein and other types of herniorrhaphy are scarce and complication rates vary widely. Further long-term studies are needed to reveal the true spectrum of benefits and harms of the different inguinal hernia repair techniques. TRIAL REGISTRATION: Registered on August 25, 2009 at the Dutch Trial Registry ( www.trialregister.nl ) NTR1853.

Unchanged muscle fiber conduction velocity relates to mild acidosis during exhaustive bicycling.

Muscle fiber conduction velocity (MFCV) has often been shown to decrease during standardized fatiguing isometric contractions. However, several studies have indicated that the MFCV may remain constant during fatiguing dynamic exercise. It was investigated if these observations can be related to the absence of a large decrease in pH and if MFCV can be considered as a good indicator of acidosis, also during dynamic bicycle exercise. High-density surface electromyography (HDsEMG) was combined with read-outs of muscle energetics recorded by in vivo (31)P magnetic resonance spectroscopy (MRS). Measurements were performed during serial exhausting bouts of bicycle exercise at three different workloads. The HDsEMG recordings revealed a small and incoherent variation of MFCV during all high-intensity exercise bouts. (31)P MRS spectra revealed a moderate decrease in pH at the end of exercise (~0.3 units down to 6.8) and a rapid ancillary drop to pH 6.5 during recovery 30 s post-exercise. This additional degree of acidification caused a significant decrease in MFCV during cycling immediately after the rest period. From the data a significant correlation between MFCV and [H(+)] ([H(+)] = 10(-pH)) was calculated (p < 0.001, Pearson's R = -0.87). Our results confirmed the previous observations of MFCV remaining constant during fatiguing dynamic exercise. A constant MFCV is in line with a low degree of acidification, considering the presence of a correlation between pH and MFCV after further increasing acidification.

Socio-economic status and physical activity among adolescents: the mediating role of self-esteem.

OBJECTIVES: Physical activity is an essential part of a healthy lifestyle in adolescence. Previous studies have shown physical activity to be associated with socio-economic status and self-esteem; the latter association may mediate the former, but evidence on this is lacking. The aim of this study was to explore the associations of socio-economic status and the self-esteem of adolescents with physical activity, and their joint effects. METHODS: A sample of 3694 elementary-school students from Slovakia (mean age 14.3 years, 49% boys) completed the Rosenberg Self-esteem Scale and answered questions about the frequency of their physical activity and their parents' educational level. RESULTS: Adolescents with higher socio-economic status were significantly more likely to report physical activity on ≥5 days/week and to report higher self-esteem. In logistic regression, the association between socio-economic status and physical activity decreased after including self-esteem, suggesting that at least a part of this association is mediated by self-esteem. CONCLUSIONS: To conclude, youths from lower socio-economic groups have already been identified as a target group, for intervention. These findings suggest that it is important for promotion programmes to focus not only on the enhancement of their physical activity, but also on their self-esteem as a possible mediator.

Age-related changes in motor unit number estimates in adult patients with Charcot-Marie-Tooth type 1A.

BACKGROUND: Charcot-Marie-Tooth disease type 1A (CMT1A) is known as a demyelinating hereditary neuropathy. Secondary axonal dysfunction is the most important determinant of disease severity. In adult patients, clinical progression may be because of further axonal deterioration as was shown with compound muscle action potential (CMAP) amplitude reductions over time. The motor unit number estimation (MUNE) technique may be more accurate to determine the number of axons as it is not disturbed by the effect of reinnervation. The purpose of this study was to investigate the number and size of motor units in relation to age in patients and controls. METHODS: In a cross-sectional design, we assessed arm and hand strength and performed electrophysiological examinations, including CMAP amplitudes and MUNE of the thenar muscles using high-density surface EMG in 69 adult patients with CMT1A and 55 age-matched healthy controls. RESULTS: In patients, lower CMAP amplitudes and MUNE values were related to hand weakness. The CMAP amplitude and MUNE value of the thenar muscles were significantly lower in patients than in controls. CMAP amplitudes declined with age in controls, but not in patients. MUNE values declined with age in both patients and controls. CONCLUSIONS: The age-dependent decrease in the number of motor units was not significantly different between patients with CMT1A and controls, indicating that loss of motor units in adult patients is limited.

Gender differences in adolescent health-related behaviour diminished between 1998 and 2006.

OBJECTIVES: Male teenagers used to smoke more than females, but this male:female ratio has reversed in several European countries over recent decades. The aim of this study was to assess whether a similar shift in gender differences in smoking and other health-related behaviours has occurred in Slovak adolescents over the last decade. STUDY DESIGN: Cross-sectional study. METHODS: Data were collected in 1998 (n=2616, 52.4% male, mean age 14.9±0.6 years, response rate 96.3%) and 2006 (n=1081, 47.0% male, mean age 14.3±0.6 years, response rate 93.0%). Changes in gender-specific prevalence rates for smoking, alcohol consumption and lack of physical activity were assessed for both cohorts overall and by socio-economic group using the highest educational level of the parents. RESULTS: Statistically significant changes occurred in the male:female ratios for smoking and lack of physical activity but not for alcohol consumption. The prevalence of smoking in males dropped below that in females, and the physical activity of females increased substantially. However, changes in gender ratios varied strongly by socio-economic group. The greatest shift in the gender ratio for smoking occurred in the middle socio-economic group, showing an increase in the entire sample. Changes in gender ratios over time among adolescents from the highest socio-economic group were much smaller. CONCLUSIONS: The behaviour of Slovak female adolescents has become similar to that of their male peers in terms of smoking and physical activity. This shift in the gender ratio in Slovakia over the last decade mimics the shift in Western Europe from approximately two decades ago.

Direct application of an ECG-based sleep staging algorithm on reflective photoplethysmography data decreases performance.

OBJECTIVE: The maturation of neural network-based techniques in combination with the availability of large sleep datasets has increased the interest in alternative methods of sleep monitoring. For unobtrusive sleep staging, the most promising algorithms are based on heart rate variability computed from inter-beat intervals (IBIs) derived from ECG-data. The practical application of these algorithms is even more promising when alternative ways of obtaining IBIs, such as wrist-worn photoplethysmography (PPG) can be used. However, studies validating sleep staging algorithms directly on PPG-based data are limited. RESULTS: We applied an automatic sleep staging algorithm trained and validated on ECG-data directly on inter-beat intervals derived from a wrist-worn PPG sensor, in 389 polysomnographic recordings of patients with a variety of sleep disorders. While the algorithm reached moderate agreement with gold standard polysomnography, the performance was significantly lower when applied on PPG- versus ECG-derived heart rate variability data (kappa 0.56 versus 0.60, p < 0.001; accuracy 73.0% versus 75.9% p < 0.001). These results show that direct application of an algorithm on a different source of data may negatively affect performance. Algorithms need to be validated using each data source and re-training should be considered whenever possible.

Parental divorce and adolescent drunkenness: role of socioeconomic position, psychological well-being and social support.

BACKGROUND: The aim of this cross-sectional study was to explore the association between parental divorce and adolescent drunkenness in the last 4 weeks and the contribution of socioeconomic position, family structure, social support from family and well-being to this association. METHODS: We obtained data on 3,694 elementary school students from several cities in Slovakia (mean age 14.3, 49.0% males; response rate 93%). Respondents completed questionnaires on how often they had been drunk in the last 4 weeks, whether their parents were divorced, their socioeconomic position (education of parents, family affluence), the composition of the household (one or two parents/step-parents), social support from the family and their own well-being. RESULTS: Parental divorce was found to have an effect on adolescent drunkenness in the last 4 weeks, as well as high socioeconomic position, low social support from the family and high depression/anxiety. The effect of divorce on drunkenness decreased only slightly after adding social support into the model. CONCLUSION: Our findings indicate that parental divorce has a persistent influence on risk behavior independent of the influence of socioeconomic position and well-being. Parental divorce may increase the likelihood of drunkenness more than other factors such as low parental support and poor socioeconomic position.

Impact of fatigue on quality of life in patients with Parkinson's disease.

BACKGROUND AND PURPOSE: Fatigue is frequent and important in the lives of Parkinson's disease (PD) patients. It is multidimensional, with physical and mental aspects. The aim of our study was to explore the impact of fatigue on quality of life (QoL) for PD patients. METHODS: The sample consisted of 175 PD patients from Eastern Slovakia (52% males, mean age 68.2 +/- 9.2, mean disease duration 7.4 +/- 6.7). The Multidimensional Fatigue Inventory (five dimensions), the Parkinson's Disease Quality of Life Questionnaire (eight dimensions) and the Unified Parkinson's Disease Rating Scale were used. Demographic data were obtained in a structured interview. Fisher's exact test, t-test, and multiple linear regression analysis were used. RESULTS: Different aspects of fatigue selectively explained different domains of QoL - physical dimensions of fatigue were connected with Mobility and Activities of daily living; mental fatigue dimensions affected Cognition, Emotional well-being, Communication and Activities of daily living; general fatigue was related to Bodily discomfort. The explained variances varied from 5% (Social support) to 65% (Activities of daily living). CONCLUSION: Fatigue combined with worse functional status appears to be a significant contributor to poor quality of life. Its multidimensional construct can be used to develop strategies for improving specific aspects of fatigue to improve QoL for PD patients.

Mastery, functional disability and perceived health status in patients with multiple sclerosis.

BACKGROUND AND PURPOSE: Multiple sclerosis (MS) is a chronic disease that is difficult to predict and to cope with. Mastery refers to the extent to which patients see themselves as being in control of the forces that affect their lives. It may play an important role in perceived health status and well-being. The purpose of this study was to clarify whether mastery is associated with functional disability and perceived health status in MS patients and how such an association might function. METHODS: Two hundred and three MS patients completed the Short-Form-36 Health Survey as well as the Pearlin-Schooler Mastery Scale. Functional disability was assessed using the Kurtzke Expanded Disability Status Scale. Hierarchical multiple linear regression analyses were performed on the data from two MS age groups: <45 and > or =45 years of age. RESULTS: Functional disability was negatively associated with perceived physical health status in both age groups and with perceived mental health status in younger age group. Mastery was positively associated with perceived health status in older age group. DISCUSSION: The findings confirm that mastery might be helpful for older MS patients. Education strategies for MS patients aimed at personal empowerment for the maintaining of physical and mental well-being may be important.

EuroSCORE predicts poor health-related physical functioning six month postcoronary artery bypass graft surgery.

AIM: The objectives of this study are to test whether the European system of cardiac-operative risk evaluation score (EuroSCORE) is associated with preoperative health-related quality of life (HRQoL), and whether it is a predictor of mental and physical health-related quality of life six months after coronary artery bypass grafting (CABG). METHODS: A longitudinal observational study was carried out among 181 patients who underwent CABG. Physical and mental domains of quality of life were measured using SF-36 and risk stratification was estimated using the EuroSCORE. A post hoc test (with Bonferroni correction) was used to determine whether EuroSCORE was associated with preoperative HRQoL, LOS and postoperative rate of complications. Hierarchical regression analysis was performed to explore the associations between EuroSCORE, postoperative events and postoperative HRQoL. RESULTS: EuroSCORE is associated with physical functioning before and after CABG and a higher EuroSCORE is a predictor of poor physical functioning and not a predictor of the mental domains of quality of life, while smoking predicted bodily pain after CABG. Furthermore, readmission within six weeks after discharge was a predictor of poor physical functioning, physical role and general health. Moreover, post hoc tests showed statistically significant and clinically relevant differences in physical functioning between low-risk and high-risk EuroSCORE classes, and between medium and high classes at baseline and six months after CABG. High-risk patients had more perioperative complications and longer lengths of stay, as compared to low-risk patients. CONCLUSION: EuroSCORE is a predictor of poor self-reported physical functioning six months after CABG and is not a predictor of mental functioning.

Stability and relative validity of the Multiple Sclerosis Impact Profile (MSIP).

OBJECTIVE: To examine the stability and relative validity of the Multiple Sclerosis Impact Profile (MSIP) in criterion-related groups. The MSIP is a disease-targeted health impact measure based on a selection of International Classification of Functioning, Disability and Health (ICF) aspects selected by 98 patients and medical and non-medical health professionals. METHOD: Data were obtained from a postal survey of 377 individuals with Multiple Sclerosis (MS) attending the MS centre of the University Medical Center Groningen (UH) and 153 subjects from the MS patients' association. Stability was tested with t-tests for paired samples and intraclass correlation coefficients for repeated measures in a sample of 251 individuals from the UH sample. The Relative Validity (RV) was estimated using the Short Form Questionnaire (SF-36), the World Health Organization Quality of Life-BREF (WHOQOL-BREF), the Disability and Impact Profile (DIP), the Impact on Autonomy Questionnaire (IPAQ) and the Groningen Activity Restriction Scale (GARS). RESULTS: These indicate that the MSIP is a stable measure in time. MSIP scales showed satisfactory and strong RV. In general, the domain-specific activities and participation measures (GARS and IPAQ) performed equally or slightly better than the comparable MSIP-scales, while the MSIP performed better than the multidimensional health impact measures (SF-36, DIP and WHOQOL-BREF). CONCLUSION: The MSIP demonstrated good stability and RV compared to generic health impact and domain-specific measures.

Effects of vibration-induced fatigue on the H-reflex.

Vibration exercise (VE) has been suggested as an effective training for improving muscle strength and coordination. However, the underlying physiological adaptation processes are not yet fully understood, limiting the development of safe and effective exercise protocols. To better understand the neuromuscular responses elicited by VE, we aimed at investigating the acute effects of superimposed vibration on the Hoffmann reflex (H-reflex), measured after fatiguing exercise. Twenty-five volunteers performed four isometric contractions of the right Flexor Carpi Radialis (FCR) with baseline load at 80% of their maximal voluntary contraction (MVC), both with no vibration and with superimposed vibration at 15, 30, and 45 Hz. Fatigue was estimated by MVC test and estimation of electromyographic spectral compression. H-reflex suppression was estimated as the relative decrease after exercise. Our results show that fatiguing exercise determined a decrease in H-reflex amplitude compared to rest condition while vibration determined a lower H-reflex suppression as compared to no vibration. The superimposition of 30-Hz vibration determined the largest acute reduction in force generating capacity (36 N, p < 0.05) and the lowest H-reflex suppression (20%, p < 0.05). These results suggest VE to be particularly suitable in rehabilitation programs for rapid restoration of muscle form and function after immobilization periods.

The transinguinal preperitoneal technique (TIPP) in inguinal hernia repair does not cause less chronic pain in relation to the ProGrip technique: a prospective double-blind randomized clinical trial comparing the TIPP technique, using the PolySoft mesh, with the ProGrip self-fixing semi-resorbable mesh.

BACKGROUND: Position of the mesh and the method of fixation are important in the occurrence of chronic pain in inguinal herniorrhaphy. An RCT was conducted to evaluate chronic pain after transinguinal preperitoneal (TIPP) repair compared with a Lichtenstein-like repair with a semi-resorbable self-fixing mesh (ProGrip). METHODS: Patients with a primary unilateral inguinal hernia were randomized either to the TIPP (PolySoft mesh) or to repair with a ProGrip mesh. Primary objective was the occurrence of chronic pain after surgery. Secondary objectives were, i.e., recurrences, complications, and quality of life. Follow-up occurred after 2 weeks, 3 months, and 1 year. Patients and physicians were blinded. RESULTS: Two hundred and fifty-eight patients were randomized to TIPP or ProGrip mesh repair. Two hundred and thirty-eight were included in the analysis: 122 in the TIPP group and 116 in the ProGrip group. Baseline characteristics were compatible. After 2 weeks and 3 months, there was significantly more moderate and severe pain in the ProGrip group on different pain scores. Median pain scores were very low in both groups after 3 months and 1 year (0-0.5 on a scale of 0-10). There was no difference in pain scores between both groups after 1 year. Recurrence rates were low; three patients in each group (2.6 % ProGrip and 2.5 % TIPP). CONCLUSION: There was no significant difference in chronic pain between the inguinal repairs with the use of a ProGrip mesh compared with a TIPP repair at 1 year after surgery. In both groups, the occurrence of chronic pain was low.

Motor unit activity within the depth of the masseter characterized by an adapted scanning EMG technique.

OBJECTIVE: To study motor unit activity in the medio-lateral extension of the masseter using an adapted scanning EMG technique that allows studying the territories of multiple motor units (MUs) in one scan. METHODS: We studied the m. masseter of 10 healthy volunteers in whom two scans were performed. A monopolar scanning needle and two pairs of fine-wire electrodes were inserted into the belly of the muscle. The signals of the fine wire electrodes were decomposed into the contribution of single MUs and used as a trigger for the scanning needle. In this manner multiple MU territory scans were obtained simultaneously. RESULTS: We determined 161 MU territories. The maximum number of territories obtained in one scan was 15. The median territory size was 4.0mm. Larger and smaller MU territories were found throughout the muscle. CONCLUSIONS: The presented technique showed its feasibility in obtaining multiple MU territories in one scan. MUs were active throughout the depth of the muscle. SIGNIFICANCE: The distribution of electrical and anatomical size of MUs substantiates the heterogeneous distribution of MUs throughout the muscle volume. This distributed activity may be of functional significance for the stabilization of the muscle during force generation.