Effects of high-frequency repetitive transcranial magnetic stimulation on reach-to-grasp performance in individuals with Parkinson's disease: a preliminary study.

Individuals with Parkinson's disease (PD) have deficits in reach-to-grasp (RTG) execution and visuospatial processing which may be a result of dopamine deficiency in two brain regions: primary motor cortex (M1) and dorsolateral prefrontal cortex (DLPFC). We hypothesized that improvement following M1 stimulation would be the result of a direct impact on motor execution; whereas, DLPFC stimulation would improve the role of DLPFC in visuospatial processing. The aim of pilot study was to investigate the effects of HF-rTMS on RTG performance by stimulating either M1 or DLPFC. Thirty individuals with PD participated (H&Y stages I-III). All of them were more affected on the right side. Participants were allocated into three groups. The DLPFC group received HF-rTMS over left DLPFC; while, the M1 group received HF-rTMS over left M1 of extensor digitorum communis representational area. The control group received HF-rTMS over the vertex. Before and immediately post HF-rTMS, right-hand RTG performance was measured under no barrier and barrier conditions. Additionally, TMS measures including motor-evoked-potential (MEP) amplitude and cortical silent period (CSP) were determined to verify the effects of HF-rTMS. For the results, there were no significant differences among the three groups. However, only the M1 group showed a significant decrease in movement time immediately after HF-rTMS for a barrier condition. Moreover, the M1 group showed a near-significant increase in hand opening and transport velocity. As for the DLPFC group, there was a near-significant increase in temporal transport-grasp coordination and a significant increase in velocity. Increased MEP amplitudes and a significantly longer CSP in the M1 and DLPFC groups confirmed the effects of HF-rTMS. Regarding non-significant results among the three groups, it is still inconclusive whether there were different effects of the rTMS on the two stimulation areas. This is a preliminary study demonstrating that HF-rTMS to M1 may improve RTG execution; whereas, HF-rTMS to DLPFC may improve visuospatial processing demands of RTG.

Impaired Reach-to-Grasp Actions during Barrier Avoidance in Individuals with Parkinson's Disease.

OBJECTIVE: To determine the kinematics and coordination while performing reach-to-grasp (RTG) actions under barrier avoidance condition in individuals with Parkinson's disease (PD). MATERIAL AND METHOD: Right handed idiopathic PDs (Hoehn and Yahr stage 2-3) (n = 20) and age-matched controls (n = 10) without dementia and psychological impairment were recruited. They were asked to perform RTG "as soon as you see the light and as fast as you can" with their right hands under barrier condition. The RTG performance were assessed in three domains, planning, execution (or kinematics), and coordination. The planning was measured by reaction time. The kinematics variables were movement time, maximum velocity, time to maximum velocity, deceleration time, maximum aperture, time to maximum aperture, aperture closure time, and aperture closure distance. The coordination was assessed using a cross correlation analysis between transport velocity and aperture size, which consisted of maximal correlation coefficient (rmax) and associated time lag (Tmax). RESULTS: Compared to the controls, the PD group had delayed planning. In execution domain, they showed decreased maximum velocity, smaller amplitude of maximum aperture, and prolonged all raw times comparing to controls. When considering the coordination, they had only prolonged T. than controls. CONCLUSION: PD participants with mild to moderate impairment showedpoorer RTG planning, execution, and coordination during barrier avoidance when compared to age-matched controls.

Evaluation of sleep disorders in Parkinson's disease: a comparison between physician diagnosis and self-administered questionnaires.

OBJECTIVE: The objective of the present study was to compare a physician's diagnosis of sleep disorders in patients with Parkinson's disease (PD) during clinical evaluation of sleep disorders diagnosed by validated questionnaires. MATERIAL AND METHOD: Patients with PD at the Parkinson's clinic at Siriraj Hospital were included in this prospective cross-sectional study. Patients completed the Modified Parkinson's Disease Sleep Scale (MPDSS), Thai Epworth Sleepiness Scale (Thai-ESS), Scales for Outcomes in Parkinson's Disease-Sleep Scale questionnaire (SCOPA), Berlin questionnaire (Thai version), and Siriraj sleep questionnaire (SSQ). Thereafter, attending physicians diagnosed sleep disorders based on patient evaluation. RESULTS: One hundred twenty patients with PD participated in the present study. Among them, 73 (60.8%) were males, the mean age was 61.5 +/- 12.0 years, and the mean body mass index (BMI) was 22.7 +/- 3.5 kg/m2 (BMI > or = 30 kg/m2 in 1.7% of patients). The study demonstrated a prevalence of overall sleep disorders in 59.2% of patients based on physician diagnosis and 81.7% of patients based on the MPDSS questionnaire. The ESS was > 10 in 29.2% of the patients. High risk for obstructive sleep apnea was observed in 28.3% (Berlin) and 42% (MPDSS) of patients (15% by both). SSQ detected all sleep disorders in 86.7% of the population, and its results correlated with the MPDSS. CONCLUSION: Sleep disorders are common in patients with PD but remain underestimated because they are not routinely screened in clinical practice. This study demonstrates the use of validated questionnaires to efficiently detect and classify patients with PD at risk for common sleep disorders.

Prevalence of Thai patients with advanced Parkinson's disease and external validation of the 5-2-1 Criteria and the CDEPA Questionnaire: A single-centered, cross-sectional study.

BACKGROUND: Advanced stage of Parkinson's disease (APD) diagnosis is challenging for general neurologists. The 5-2-1 Criteria and the Cuestionario De Enfermedad de Parkinson Avanzada (CDEPA) have been validated for screening for APD. OBJECTIVE: This article reports the period-prevalence of APD defined by a movement disorder expert, the 5-2-1 Criteria, and CDEPA and to improve the screening performance of the 5-2-1 Criteria METHODS: A cross-sectional retrospective study at the Parkinson's disease (PD) clinic of a tertiary hospital in Bangkok, Thailand amongst all PD patients aged ≥ 18 years was performed from January 2016 to January 2020. We compared the characteristics of APD and non-APD patients. We externally validated the 5-2-1 Criteria and CDEPA. We explored improving the 5-2-1 Criteria. RESULTS: Of 480 PD patients with complete data, the period-prevalence of APD by the movement disorder expert, the 5-2-1 Criteria and CDEPA were 37.1 %, 48.5 %, and 27.5 %, respectively. Adding requiring help with an activity of daily living and freezing of gait to the original 5-2-1 Criteria enhanced the sensitivity from 86.5 % (95 %CI 80.6, 91.2) to 94.9 % (95 %CI 90.6, 97.7) and negative predictive value (NPV) from 90.3 % (95 %CI 85.9, 93.7) to 96 % (95 %CI 92.6, 98.2). However, the CDEPA had a sensitivity of 62.9 % (95 %CI 55.4, 70) and NPV of 81.0 (95 %CI 76.5, 85). CONCLUSION: The 5-2-1 Criteria had a good screening tool performance for general neurologists to refer APD patients for optimal treatments. The modified 5-2-1 Criteria had better performance than the original one. External validation is needed.

Validation of the Thai Version of the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale.

OBJECTIVE: This study aims to validate the Thai translation of the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS). METHODS: The English version was translated into Thai and then back-translated into English. The translated version underwent 2 rounds of cognitive pretesting to assess the ease of comprehension, ease of use and comfort with the scale. Then, it underwent large clinimetric testing. RESULTS: The Thai version was validated in 354 PD patients. The comparative fit index (CFI) for all four parts of the Thai version of the MDS-UPDRS was 0.93 or greater. Exploratory factor analysis identified isolated item differences in factor structure between the Thai and English versions. CONCLUSION: The overall factor structure of the Thai version was consistent with that of the English version based on the high CFIs (all CFI ≥ 0.90). Hence, it can be designated the official Thai version of the MDS-UPDRS.

Combined ablative neurosurgical procedures in a patient with mixed spastic and dystonic cerebral palsy.

BACKGROUND: Harmful generalized spasticity is an obstacle in rehabilitation and caregiving. Neurosurgical intervention is a therapeutic option for patients with severe spasticity who do not respond to nonoperative management. Currently, intrathecal baclofen therapy (ITB) is a good alternative treatment for such patients. However, the ITB device is costly and the intrathecal drug is not available in Thailand. CASE DESCRIPTION: We report a combined use of ablative neurosurgical procedures in a patient with severe generalized spasticity and disabling cervical dystonia (CD). The assembled operations including selective peripheral denervation for CD, microsurgical dorsal root entry zone lesion for upper limb spasticity, and selective dorsal rhizotomy for lower limb spasticity were conducted in a single session. Furthermore, recurrent spasticity of the upper extremities was subsequently treated by selective peripheral neurotomy. RESULTS: The spasticity and CD totally disappeared after all operations. The patient became able to sit and perform head turning. Additionally, we also found an improvement in swallowing and the voluntary movement of the lower limbs.

SW2-year outcomes of subthalamic deep brain stimulation for idiopathic Parkinson's disease.

BACKGROUND: Deep brain stimulation of the subthalamic nucleus (STN-DBS) is the recent surgical treatment of choice for patients with idiopathic Parkinson's disease (PD) complicated by motor fluctuation and disabling dyskinesia. OBJECTIVE: To study 2 years clinical outcomes, changes of medication and complications following STN-DBS in patients with advanced PD. MATERIAL AND METHOD: Twenty-seven patients with 2-year follow-up and complete data were enrolled for retrospective evaluation of Unified Parkinson's Disease Rating Scale (UPDRS) and levodopa equivalent dose (LED). Postoperative UPDRS at 6-month, 1-year and 2-years were compared with the preoperative corresponding UPDRS. Postoperative LED at 2 years was compared with the preoperative baseline. Statistical analysis was performed with paired t-test. Additionally, 62 patients with STN-DBS were enrolled for evaluation of treatment complications. RESULTS: Of 27 patients with complete 2-years follow-up, preoperative dopamine challenge test showed 50.6% improvement of motor score (UPDRS axis III). Mentation, behavior and mood (UPDRS axis I) were not significantly improved in each subscore, but significantly improved in the total score. Marked improvement of activities of daily living (UPDRS axis II) and complications of therapy (UPDRS IV) was found. Two-year postoperative motor score (UPDRS axis III) during "off medication-on stimulator" showed progressive and dramatic improvement by mean of 59.83%. The present study also revealed significant improvement of motor score (UPDRS axis III) during "on medication-on stimulator" in some items. A significant 33.4% reduction of LED was noted. Of 62 patients with bilateral STN-DBS, there was 1 asymptomatic intracerebral hemorrhage (0.8% per side), 2 speech difficulty (3.2%), 1 transient confusion (1.6%), 2 transient hypomania (3.2%), 1 stimulation induced hemiballism (1.6%), 1 wound infection (1.6%) and 1 lead malposition (0.8% per side). CONCLUSION: STN-DBS is a safe and effective treatment for PD complicated by motor fluctuation or dyskinesia. The operative outcomes show long-term improvement of activities of daily living, motor function and reduction of medication and drug-related complications.

Establishing apomorphine treatment in Thailand: understanding the challenges and opportunities of Parkinson's disease management in developing countries.

INTRODUCTION: The increasing global burden of Parkinson's disease (PD) poses a particular challenge for developing countries, such as Thailand, when delivering care to a geographically diverse populace with limited resources, often compounded by a lack of expertise in the use of certain PD medications, such as device-aided therapies (DAT). AREAS COVERED: A panel of local, regional, and international PD experts convened to review the unmet needs of PD in Thailand and share insights into effective delivery of DAT, focusing on experience with apomorphine infusion. Despite its proven efficacy and safety, implementation of apomorphine infusion as a new option was not straightforward. This has prompted a range of health-care professional and patient-focused initiatives, led by the Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders in Bangkok, to help establish a more coordinated approach to PD management throughout the country and ensure patients have access to suitable treatments. EXPERT OPINION: Overcoming the challenges of education, proficiency, resource capacity and standard of care for PD patients in developing countries requires a coordinated effort both nationally and beyond. The best practices identified in Thailand following the introduction of apomorphine infusion might be helpful for other countries when implementing similar programs.

Asian perspectives on the recognition and management of levodopa 'wearing-off' in Parkinson's disease.

Most Parkinson's disease patients will receive levodopa therapy, and of these, the majority will develop some levodopa-induced complications. For many patients, the first complication to develop is the decline in the duration of therapeutic benefit of each levodopa dose, a phenomenon commonly termed 'wearing-off'. There is already extensive literature documenting the epidemiology and management of wearing-off in Parkinson's disease patients of western descent. However, data derived from these studies might not always apply to patients of Asian descent due to genetic variations, differences in co-morbidities or non-availability of certain drugs. This review summarizes the current literature regarding the epidemiology of wearing-off in Asian (including Arab) patients and discusses the management issues in the context of drug availability in Asia.

Efficacy and safety of piribedil in early combination with L-dopa in the treatment of Parkinson's disease: a 6-month open study.

BACKGROUND: Piribedil is a non-ergot D2/D3 dopamine agonist with antagonistic effect on alpha2-adrenoceptors and lack of agonist properties at 5-HT2A/2C receptors. Previous studies indicated its efficacy in monotherapy as well as in combinatio' s disease in L-dopa-treated parkinsonian patients. PATIENTS AND METHOD: A 6-month, open-labeled, multicenter study was conducted in Thai Parkinsonian patients who were insufficiently controlled by L-dopa (< or = 600 mg/day). Piribedil 50 mg in retard form was titrated upward to 150 mg/day (50 mg tid) by the 5th week and up to 6 months as an add-on treatment. L-dopa daily dose was kept stable until the 3rd month and could be adjusted afterwards. The main efficacy parameter was the change in UPDRS part III score versus baseline over Full Analysis Set, score variation, and percentage of responders defined by at least 30% decrease from baseline of total UPDRS part III score. The secondary efficacy criteria were changes in L-dopa dose between the third month and the end of the study, UPDRS part II score variation, Hoehn and Yahr stage variation and Schwab and England Activities of Daily Living Scale variation. The acceptability of piribedil was assessed by physical examination, weight, blood pressure and heart rate as well as the reported adverse events. RESULTS: Twenty-nine patients (55.2% male) with the mean age of 64.0 +/- 7.2 years and mean duration of disease of 18.3 +/- 8.2 months were recruited The mean UPDRS part III score at baseline was 19.8 +/- 11.4. After 6-month treatment with piribedil, mean UPDRS part III score significantly decreased to 6.6 +/- 4.7 (p < 0.0001) with mean score variation of 13.3 +/- 10.3. Twenty-seven patients (93.1%) were responders. Mean UPDRS part II score was significantly decreased from 7.2 +/- 5.4 at baseline to 2.7 +/- 2.1 at the end of 6 months (p < 0.0001). Hoehn and Yahr stage and Schwab and England Activities of Daily Living Scale were also significantly improved Reported adverse events were mainly gastrointestinal symptoms. Blood pressure and heart rate were not significantly changed during the study period. Peak dose dyskinesia was reported only in one patient. Two patients (6.9%) were withdrawn because of adverse events. CONCLUSION: Piribedil was effective on motor symptoms during a 6-month treatment in early parkinsonian patients insufficiently controlled by L-dopa and it was well tolerated.

Spatiotemporal gait parameters for patients with Parkinson's disease compared with normal individuals.

BACKGROUND: Gait initiation is a major motor problem for patients with Parkinson's disease (PD). To understand the gait initiation in patients with PD, fluctuation on the first three steps of initiation was examined METHODS: Force distribution measurement platform was used to record gait initiation in 10 patients with PD and healthy participants. Step length, step time and step width, as well as its coefficient of variation (CV) were investigated RESULTS: The findings demonstrated significant main effect of group on step length (p < 0.001), step time (p = 0.034) and step width (p = 0.002), significant main effect of step on step time (p < 0.001) and step width (p < 0.001). No interaction between group and step (p > 0.05) was found on the variables. Compared with healthy participants, patients with PD showed significantly shorter step length in the first (p < 0.001), second (p = 0.001) and third (p = 0.001) steps and longer step time in the second step (p < 0.001). No difference in CV (p > 0.05) of the variables between groups comparison. Both groups had significant longer step time in the first step compared with the second step (PD, p < 0.001; healthy participants, p < 0.001) and the third steps (PD, p < 0.001; healthy participants, p < 0.001). They demonstrated significant wider step width in the first step when compared with the second step (PD, p = 0.043; healthy participants, p < 0.001) and the third steps (PD, p = 0.002; healthy participants, p < 0.001). CONCLUSION: Patients with PD showed shorter step length of all steps, longer step time in the second step and similar step width when compared with healthy participants. Among the three steps, both groups demonstrated longer step time and wider step width in the first step when compared with other two step.