Updates in Parkinson's Disease Integrative Therapies: an Evidence-Based Review.

PURPOSE OF REVIEW: This review summarizes recent evidence-based integrative therapies for Parkinson's disease (PD) that may improve motor and non-motor symptoms, enhance quality of life, and alter disease progression. RECENT FINDINGS: Imaging studies have demonstrated that aerobic exercise changes brain structure and function, while strength training improves posture and balance. Loneliness is associated with worsening PD severity, but social prescribing and cognitive behavioral therapy may effectively foster connections. Ayurvedic and traditional Chinese medicine practices including yoga, meditation, tai chi, and acupuncture may help improve mobility, mood, sleep, and quality of life. Art therapy enhances visuospatial skills, whereas music and dance therapy can alleviate freezing of gait. Several studies demonstrate successful use of these integrative strategies virtually, thereby improving patient accessibility and participation. PD management has broadened to include integrative approaches combining conventional and complementary therapies. Potential benefits of movement, nutrition, sleep, socialization, and mind-body practices have been confirmed with several recent randomized controlled trials.

Updates in Functional Movement Disorders: from Pathophysiology to Treatment Advances.

PURPOSE OF REVIEW: This review discusses advances in functional movement disorders (FMD) over the past 3 years, with a focus on risk factors, diagnosis, pathophysiology, neuroimaging studies, and treatment. RECENT FINDINGS: The past decade has brought a revived interest in functional movement disorders, with a growing number of studies exploring pathophysiological mechanisms. Here, we review recent studies demonstrating changes in attention, emotional and sensorimotor function in FMD. Through international collaborative efforts, progress has been made in defining biomarkers and outcome measures, an important prerequisite towards standardization of diagnosis and reporting of outcomes in clinical trials. Of particular interest are neuroimaging studies demonstrating functional and structural changes in motor and emotional brain circuits, deepening our understanding of FMD as a neurocircuit disorder and potentially paving the way towards new treatments. Currently available treatment modalities have shown successful outcomes via outpatient, inpatient, and virtual delivery. The last 3 years have seen tremendous efforts to better understand, diagnose, and treat FMD. The disease model has been broadened to include a biopsychosocial formulation, and insights on the pathophysiology on FMD are informing treatment efforts. Several international multidisciplinary research collaborations are underway to define biomarkers and best outcome measures, highlighting the path towards improved standardization of future treatment trials. Additionally, the rise of telemedicine during the COVID-19 pandemic has reduced geographic barriers and paved the way for virtual therapy sessions and self-guided programs.

Longer-term Baerveldt to Trabectome glaucoma surgery comparison using propensity score matching.

PURPOSE: To apply propensity score matching to compare Baerveldt glaucoma drainage implant (BGI) to Trabectome-mediated ab interno trabeculectomy (AIT). Recent data suggests that AIT can produce results similar to BGI which is traditionally reserved for more severe glaucoma. METHODS: BGI and AIT patients with at least 1 year of follow-up were included. The primary outcome measures were intraocular pressure (IOP), number of glaucoma medications, and a Glaucoma Index (GI) score. GI reflected glaucoma severity based on visual field, the number of preoperative medications, and preoperative IOP. Score matching used a genetic algorithm consisting of age, gender, type of glaucoma, concurrent phacoemulsification, baseline number of medications, and baseline IOP. Patients with neovascular glaucoma, with prior glaucoma surgery, or without a close match were excluded. RESULTS: Of 353 patients, 30 AIT patients were matched to 29 BGI patients. Baseline characteristics including, IOP, the number of glaucoma medications, type of glaucoma, the degree of VF loss and GI were not significantly different between AIT and BGI. BGI had a preoperative IOP of 21.6 ± 6.3 mmHg compared to 21.5 ± 7.4 for AIT on 2.8 ± 1.1 medications and 2.5 ± 2.3 respectively. At 30 months, the mean IOP was 15.0 ± 3.9 mmHg for AIT versus 15.0 ± 5.7 mmHg for BGI (p > 0.05), while the number of drops was 1.5 ± 1.3 for AIT (change: p = 0.001) versus 2.4 ± 1.2 for BGI (change: p = 0.17; AIT vs BGI: 0.007). Success, defined as IOP < 21 mmHg, < 20% reduction and no reoperation, was achieved at 1 year in 56% of AIT versus 55% of BGI (p > 0.05) and 50% versus 52% at 2.5 years. CONCLUSIONS: A propensity score matched comparison of AIT and BGI demonstrated a similar IOP reduction through 1 year. AIT required fewer medications.

Functional movement disorder and functional seizures: What have we learned from different subtypes of functional neurological disorders?

The objective of this paper is to compare and contrast FMD and FS, and highlight important differences in etiology and the clinical approach towards these two entities. While patients with FMD often experience abnormal movements on a daily basis, FS is characterized by paroxysmal events. Both patient populations share psychiatric and environmental comorbidities, but patients with FS may have increased anxiety and neuroticism and a higher percentage of childhood trauma. Functional MRI scans have demonstrated impaired executive control over motor behavior in both groups. FMD responds well to multidisciplinary rehabilitation-oriented treatment, while psychotherapy remains the mainstay of treatment for FS. For practicing clinicians, recognizing commonalities and differences in patients with FMD and FS is important to develop the most appropriate treatment plan.

A prospective pilot study of the effects of deep brain stimulation on olfaction and constipation in Parkinson's disease.

BACKGROUND: Previous studies suggest deep brain stimulation of the subthalamic nucleus (STN-DBS) may improve olfaction and constipation in PD, using subjective measures. OBJECTIVE: To utilize objective measures to assess olfaction and constipation in PD following STN-DBS. METHODS: In this prospective pilot study, olfaction (University of Pennsylvania Smell Identification Test [UPSIT]), bowel symptoms (ROME III questionnaires, daily bowel diaries, 100 mm visual analog scales for satisfaction with treatment and bowel habits), and motor manifestations of PD were evaluated before and after STN-DBS. Levodopa equivalent daily dose (LEDD) was calculated. RESULTS: Ten patients (8 men, mean age 67.4 ± 6.0 years) with mean PD duration of 7.5 ± 3.7 years underwent bilateral STN-DBS, with mean follow-up of 3 months for all measures, except 7 months follow-up for bowel diaries. There was improvement in the Unified Parkinson's Disease Rating Scale motor "off" scores (33.7 ± 6.7 before and 16.1 ± 10.8 after, P = 0.001). Mean UPSIT scores (20.0 ± 6.6 versus 17.5 ± 5.7, P = 0.03) worsened from severe to total hyposmia. Seven patients had baseline constipation and completed bowel diaries. There was improvement in number of complete spontaneous bowel motions (CBSM) per week (2.2 ± 1.9 before versus 4.7 ± 2.4 after, P = 0.04), satisfaction with treatment of constipation (44 ± 27 before versus 64 ± 25 after, P = 0.02), and with bowel motions (33 ± 22 before and 48 ± 20 after, P = 0.2). However, laxative use (P = 0.15) and LEDD (P = 0.15) were unchanged. CONCLUSION: Olfaction worsened while symptoms of constipation improved but did not resolve after STN-DBS.

A big white dot after CPR.

INTRODUCTION: Patients may remain comatose after the resumption of spontaneous circulation with cardiopulmonary resuscitation. A primary neurologic event may precede a cardiac standstill. CASE REPORT: We present a 33-year-old patient with successful resuscitation for pulseless electrical activity and a "normal computed tomography (CT) scan." Further scrutiny showed a hyperdense basilar artery sign ('big white dot') that led to a CT angiogram confirming an embolus to the proximal basilar artery. His examination showed fixed and dilated midsize (mesencephalic) pupils and extensor posturing. Endovascular retrieval of the clot was successful, but there was a devastating ischemic injury to the brainstem. CONCLUSION: This case reminds us to consider neurologic causes of cardiac arrest.

Similar Performance of Trabectome and Ahmed Glaucoma Devices in a Propensity Score-matched Comparison.

PURPOSE: To apply propensity score matching to Ahmed glaucoma drainage implants (AGI) to trabectome-mediated ab interno trabeculectomy (AIT). Recent data suggest that AIT can produce results similar to AGI traditionally reserved for more severe glaucoma. METHODS: AGI and AIT patients with at least 1 year of follow-up were included. The primary outcome measures were intraocular pressure (IOP), glaucoma medications, and a Glaucoma Index (GI) score. GI reflected glaucoma severity based on visual field, the number of preoperative medications, and preoperative IOP. Score matching used a genetic algorithm consisting of age, sex, type of glaucoma, concurrent phacoemulsification, baseline number of medications, and baseline IOP. Patients without a close match were excluded. RESULTS: Of 152 patients, 34 AIT patients were matched to 32 AGI patients. Baseline characteristics including ethnicity, IOP, the number of medications, glaucoma type, the degree of visual field loss and GI were not significantly different between AIT and AGI. AIT had a preoperative IOP of 23.6±8.1 mm Hg compared with 26.5+10.6 mm Hg for AGI. At 12 months, the mean IOP was 15.0±9 mm Hg for AIT versus 15.0±4 mm Hg for AGI (P=0.8), whereas the number of drops was 2.3±2.2 for AIT versus 3.6±1.3 for AGI (P=0.016). Only 6 AIT patients (17.6%) required further surgery within the first 12 months versus 9 (28%) for AGI. Success, defined as IOP<21 mm Hg, <20% reduction and no reoperation, was achieved in 76% of AIT versus 69% of AGI (P=0.48). Complications occurred in 13% of AGI and 0.8% of AIT. CONCLUSIONS: A propensity score-matched comparison of AIT and AGI showed an equivalent IOP reduction through 1 year. Surprisingly, the AGI group required more glaucoma medications than the AIT group at 6 and 12 months.

Partnership Building and Implementation of an Integrated Healthy-Aging Program.

BACKGROUND: Evidence-based interventions exist for prevention of chronic disease in older adults. Partnering with community organizations may provide a mechanism for disseminating these interventions. OBJECTIVE: To describe the partnership and program implementation by the Arthritis Foundation (AF) and the University of Pittsburgh. METHODS: The AF Exercise Program (AFEP; an existing evidence-based program) was enhanced with the "10 Keys"™ to Healthy Aging (a prevention-focused program bundling the most common risk factors for chronic disease and disability in older adults and applies behavior change strategies to enhance prevention). The program was delivered in 20 sessions over 10 weeks by community health workers in a cluster-randomized trial. LESSONS LEARNED: Partnering with an organization having an existing infrastructure supports program delivery at the community level. This partnership provided programming in 54 sites across Pittsburgh and surrounding communities. CONCLUSIONS: This collaborative partnership created a productive synergy maximizing strengths in both research and program delivery.