Post-Traumatic Stress Disorder and Risk of Degenerative Synucleinopathies: Systematic Review and Meta-Analysis.

OBJECTIVE: A systematic review was conducted to answer whether adult-onset post-traumatic stress disorder (PTSD) is associated with increased risk of Parkinson's disease (PD) and related synucleinopathies. DESIGN: A systematic search of Medline (Ovid), Embase (Elsevier), PsycInfo (Ovid), Cochrane Library (Wiley), and Web of Science (Clarivate) was performed using MeSH headings and equivalent terms for PTSD, PD, DLB, and related disorders. SETTING: No restrictions. PARTICIPANTS: Eligible articles were published in peer-reviewed journals, sampled adult human populations, and treated PTSD and degenerative synucleinopathies as exposures and outcomes, respectively. MEASUREMENTS: Extracted data included diagnostic methods, sample characteristics, matching procedures, covariates, and effect estimates. Bias assessment was performed with the Newcastle-Ottawa scale. Hazard ratios were pooled using the random effects model, and the Hartung-Knapp adjustment was applied due to the small number of studies. RESULTS: A total of six articles comprising seven unique samples (total n = 1,747,378) met eligibility criteria. The risk of PD was reported in three retrospective cohort studies and one case-control study. Risk of DLB was reported in one retrospective cohort, one case-control, and one prospective cohort study. No studies addressed potential relationships with multiple system atrophy or pure autonomic failure. Meta-analysis of hazard ratios from four retrospective cohort studies supported the hypothesis that incident PTSD was associated with PD and DLB risk (pooled HR 1.88, 95% C.I. 1.08-3.24; p = 0.035). CONCLUSIONS: The sparse literature to-date supports further investigations on the association of mid- to late-life PTSD with Parkinson's and related neurodegenerative disorders.

Dream Enactment Behaviors Associated With Posttraumatic Stress Disorder.

The investigators aimed to draw attention to current debates surrounding the etiologies of dream enactment behaviors in patients with posttraumatic stress disorder (PTSD). The phenomenological overlap between PTSD-related nocturnal symptoms, rapid eye movement sleep behavior disorder (RBD), and trauma-associated sleep disorder (TASD) is discussed. Strategies used to diagnose and manage dream enactment behaviors, whether due to RBD or another confounding sleep disorder, are considered. Finally, the need for further research on the pathophysiological overlap and integrated treatment of PTSD, RBD, and, possibly, TASD is highlighted.

Post-Traumatic Stress Disorder is Associated with further Increased Parkinson's Disease Risk in Veterans with Traumatic Brain Injury.

OBJECTIVE: Determining if traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are risk factors for Parkinson's disease (PD). This constitutes a research priority for the Veterans Administration (VA) with implications for screening policy and prevention. METHODS: Population-based, matched case-control study among veterans using VA health care facilities from October 1, 1999, to September 30, 2013. We identified 176,871 PD cases and 707,484 randomly selected PD-free matched controls. PD, TBI, and PTSD were ascertained by validated International Classification of Disease 9th revision (ICD)-9 code-based algorithms. We examined the association between both risk factors and PD using race-adjusted conditional logistic regression. RESULTS: The overall study cohort prevalence for TBImild , TBInon-mild , and PTSD was 0.65%, 0.69%, and 5.5%, respectively. Both TBI and PTSD were significantly associated with PD in single-risk factor race-adjusted analyses (conditional odds ratio [cOR] = 2.99; 95% confidence interval [CI]: 2.69-3.32), 3.82 (95% CI: 3.67-3.97), and 2.71 (95% CI: 2.66-2.77) for TBImild , TBInon-mild , and PTSD, respectively). There was suggestive positive interaction observed with comorbid PTSD/TBI in dual-risk factor analyses, with significant 2.69-fold and 3.70-fold excess relative PD risk in veterans with TBImild and TBInon-mild versus those without TBI when PTSD was present versus 2.17-fold and 2.80-fold excess risk when PTSD was absent. INTERPRETATION: Our study was the first to demonstrate that both TBI and PTSD are independently associated with increased relative PD risk in a diverse nationwide cohort of military service veterans, and the first to suggest a potential modest synergistic excess risk in those with comorbid TBI/PTSD. Longitudinal research is needed to confirm these suggestive findings. ANN NEUROL 2020 ANN NEUROL 2020;88:33-41.

Clinical Correlates of Dream Enactment Behaviors in Previously Deployed OEF/OIF/OND Veterans: An Exploratory Analysis.

OBJECTIVE: Veterans with posttraumatic stress disorder (PTSD) frequently report dream enactment behavior (DEB). Although DEBs are associated with PTSD symptoms, their relationship with other sleep disorders, including REM behavior disorder, warrants reexamination of their clinical correlates. METHODS: The investigators used a cross-sectional, exploratory analysis to compare demographic and clinical characteristics of veterans endorsing regularly occurring DEB compared with those endorsing no or infrequent DEB. The participants comprised a convenience sample of servicemembers who were previously deployed to Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) and enrolled in an ongoing cohort study. RESULTS: Of the 78 eligible participants, 19 (24.4%) endorsed DEBs occurring at least once per week in the past month. Compared with participants who reported no or infrequent DEBs, participants with regularly occurring DEBs had poorer sleep quality, greater PTSD severity, a higher number of reported mild traumatic brain injuries (mTBI) with loss of consciousness, and a higher likelihood of being diagnosed with sleep disorders. After adjustment for global sleep quality, a significant association persisted between DEBs and the number of mTBI with loss of consciousness but not between DEBs and the severity of PTSD symptoms. CONCLUSIONS: These results suggest that mTBI may disrupt neural circuits regulating sleep among OIF/OEF/OND veterans. Prospective, polysomnographic assessment of muscle tone and behavioral events during REM sleep is needed to characterize the physiology of DEBs in this population.

Integration and Extension of Specialty Mental Healthcare Services to Community Practice in Parkinson Disease.

Parkinson disease (PD) is a progressive neurodegenerative disease with a higher prevalence of neuropsychiatric symptoms compared with the general population. Symptoms such as anxiety, depression, psychosis, impulse control disorders, and cognitive impairment cause a greater worsening of quality of life than even the motor symptoms that define PD. Despite the ubiquity and impact of neuropsychiatric symptoms, specialty mental healthcare is not routinely available, accessible, or integrated in most neurology practices. Currently, training in PD-specific mental healthcare is not standard in most programs, and the need for subspecialty-trained, mental healthcare providers will only increase over time, as the prevalence of PD will more than double by 2060. Many barriers limit extension of mental healthcare into existing models of integrated or multidisciplinary care and the community at large. Foundations and professional societies have played an important role in raising awareness of mental healthcare needs in PD; however, their initiatives to promote integrated or multidisciplinary care have traditionally focused on disciplines outside of mental health such as physical, occupational, and speech therapy. This article examines these issues and suggests strategies to better address mental healthcare needs for PD patients in the future.

Perceived Treatment Status of Fluctuations in Parkinson Disease Impacts Suicidality.

OBJECTIVE: On/off motor fluctuations in Parkinson disease (PD) can be associated with extreme mood fluctuations and severe dysphoria. The impact of these affective symptoms may be overlooked in the treatment of motor fluctuations. Our goal was to examine the relationship between motor fluctuations, their treatment status, and suicidality in PD participants. METHODS: We analyzed data from the Methods of Optimal Depression Detection in Parkinson's Disease (MOOD-PD) study of 223 individuals with PD. Suicidality was measured using items from four depression scales: Hamilton Depression Rating Scale (HAM-D-17); Montgomery-Åsberg Depression Rating Scale (MADRS); Inventory for Depressive Symptomatology (IDS-C); and the self-rated Beck Depression Inventory (BDI). Multivariable Poisson regression analyses tested whether self-reported motor fluctuations and their treatment status were associated with suicidality while controlling for recognized risk factors. RESULTS: Thirty-seven participants (16.6%) self-reported suicidality and 89 (39.5%) self-reported motor fluctuations, of whom 21 (23.6%) perceived their fluctuations as untreated. Participants reporting untreated motor fluctuations more frequently had a current depressive disorder (p < 0.001) and endorsed suicidality (p = 0.006) than participants with treated or no fluctuations. They also had significantly higher total scores on the HAM-D-17, MADRS, IDS-C, and BDI depression scales (p < 0.001 for each). Regression analyses showed significant associations between untreated motor fluctuations and higher scores on suicide questions extracted from the HAM-D-17, MADRS, and IDS-C (p < 0.01 for each). CONCLUSIONS: PD patients with untreated motor fluctuations are at increased risk for suicidal thoughts and should be monitored for mood changes as treatment is adapted.

Psychiatric associations of adult-onset focal dystonia phenotypes.

BACKGROUND: Depression and anxiety frequently accompany the motor manifestations of isolated adult-onset focal dystonias. Whether the body region affected when this type of dystonia first presents is associated with the severity of these neuropsychiatric symptoms is unknown. OBJECTIVES: The aim of this study was to determine whether depression, anxiety and social anxiety vary by dystonia onset site and evaluate whether pain and dystonia severity account for any differences. METHODS: Patients with isolated focal dystonia evaluated within 5 years from symptom onset, enrolled in the Natural History Project of the Dystonia Coalition, were included in the analysis. Individual onset sites were grouped into five body regions: cervical, laryngeal, limb, lower cranial and upper cranial. Neuropsychiatric symptoms were rated using the Beck Depression Inventory, Hospital Anxiety and Depression Scale and Liebowitz Social Anxiety Scale. Pain was estimated using the 36-Item Short Form Survey. RESULTS: Four hundred and seventy-eight subjects met our inclusion criteria. High levels of depression, anxiety and social anxiety occurred in all groups; however, the severity of anxiety and social anxiety symptoms varied by onset site group. The most pronounced differences were higher anxiety in cervical and laryngeal, lower anxiety in upper cranial and higher social anxiety in laryngeal. Increases in pain were associated with worse neuropsychiatric symptom scores within all groups. Higher anxiety and social anxiety in laryngeal and lower anxiety in upper cranial persisted after correcting for pain and dystonia severity. CONCLUSION: Anxiety and social anxiety severity vary by onset site of focal dystonia, and this variation is not explained by differences in pain and dystonia severity.

Modeling anxiety in Parkinson's disease.

BACKGROUND: The aim of this work was to construct a model for anxiety in PD and compare the relative contributions of PD-specific and -nonspecific general population risk factors for anxiety in this model. METHODS: Structural equation modeling of associations of risk factors with the anxiety outcome using a cross-sectional data set of 342 patients with PD were used. RESULTS: A model with acceptable to good fit was generated that explained 65% of the variance in anxiety scores. A previous history of depression and the severity of the depressive symptoms scored on the Hamilton Depression Rating Scale were the only nonspecific variables with a direct effect on anxiety. The presence of motor fluctuations and disease-related decline in activities of daily living were PD-specific markers of anxiety. Nonspecific risk factors had a greater influence in the model than PD-specific risk factors. Standardized regression coefficients suggested that the Hamilton Depression Rating Scale score was the most important contributor to the variation in anxiety. A post-hoc analysis showed that the effects of the following variables on anxiety levels were fully mediated by depression: sex; family history of depression; previous history of anxiety; cognitive status; difficulties in non-disease-specific activities of daily living; and severity of motor signs. CONCLUSION: In this cross-sectional study, we showed that nonspecific general population risk factors are more important markers for anxiety than PD-specific risk factors. Depression was the most prominent marker. PD-specific markers for anxiety appear to be more situational and related to off periods and disease-specific disturbances of activities of daily living.

The longitudinal impact of depression on disability in Parkinson disease.

OBJECTIVE: Depression in Parkinson disease (PD) is a common problem that worsens quality of life and causes disability. However, little is known about the longitudinal impact of depression on disability in PD. This study examined the association between disability and DSM-IV-TR depression status across six years. METHODS: Longitudinal cohort study with assessments at study entry, year two, four, and six conducted in the Morris K. Udall Parkinson Disease Research Center. Recruitment totaled 137 adult men and women with idiopathic PD in which up to six years of data on demographic, motor, and non-motor variables was collected. Movement disorder specialists used the structured interview for DSM-IV-TR depressive disorders and the Northwestern Disability Scale to assess depression and disability. A generalized linear mixed model was fitted with Northwestern Disability Scale score as the dependent variable to determine the effect of baseline depression status on disability. RESULTS: A total of 43 participants were depressed at baseline compared to 94 without depression. Depressed participants were more likely to be female, were less educated, were less likely to take dopamine agonists, and more likely to have motor fluctuations. Controlling for these variables, symptomatic depression predicted greater disability compared to both never depressed (p = 0.0133) and remitted depression (p = 0.0009). Disability associated with symptomatic depression at baseline was greater over the entire six-year period compared to participants with remitted depressive episodes or who were never depressed. CONCLUSIONS: Persisting depression is associated with a long-term adverse impact on daily functioning in PD. Adequate treatment or spontaneous remission of depression improves ADL function.

Apathy in Neurodegenerative Diseases: Recommendations on the Design of Clinical Trials.

Apathy is a common feature of neurodegenerative disorders but is difficult to study in a clinical trial setting due to practical and conceptual barriers. Principal challenges include a paucity of data regarding apathy in these disorders, an absence of established diagnostic criteria, the presence of confounding factors (eg, coexisting depression), use of concomitant medications, and an absence of a gold-standard apathy assessment scale. Based on a literature search and ongoing collaboration among the authors, we present recommendations for the design of future clinical trials of apathy, suggesting Alzheimer disease and Parkinson disease as models with relevance across a wider array of neuropsychiatric disorders. Recommendations address clarification of the targeted study population (apathy diagnosis and severity at baseline), confounding factors (mood/cognition, behavior, and treatment), outcome measures, study duration, use of comparators and considerations around environment, and the role of the caregiver and patient assent. This review contributes to the search for an optimal approach to study treatment of apathy in neuropsychiatric disorders.

A Pilot Study of a Cognitive-Behavioral Treatment for Anxiety and Depression in Patients With Parkinson Disease.

Anxiety and depression often remain unrecognized or inadequately treated in patients with Parkinson disease (PD). Cognitive-behavioral therapy (CBT) is effective, but limited evidence supports its use for anxiety and depression in patients with PD. Sixteen patients with PD having significant anxiety and/or depressive symptoms were assigned to CBT or enhanced usual care. Assessments occurred at baseline, posttreatment, and 1-month follow-up. The CBT intervention included tools for anxiety, depression, and healthy living with PD symptoms. Individual sessions were delivered by telephone or in person, based on patient preference. Treatment was feasible with participants choosing 67% of sessions by telephone and 80% completed treatment. The between-group effect sizes for change scores from baseline to posttreatment and baseline to 1-month follow-up were large (posttreatment: d = 1.49 for depression and 1.44 for anxiety; 1-month follow-up: d = .73 for depression and 1.24 for anxiety), although only the posttreatment effect size for depression was significant. This pilot CBT program is feasible for treatment of anxiety and depression in patients with PD.

Mental health diagnoses and health care utilization in persons with dementia, Parkinson's disease, and stroke.

In late life, neurological disturbances, depression, and anxiety frequently complicate the clinical presentation but are often undertreated. An administrative database of 3,034 male veterans, age 55 years and older, with a diagnosis of dementia, Parkinson's disease, or stroke was examined for the prevalence of mood and anxiety disorders and mental health service use. Those with more than one of these neurological diagnoses were most likely to have a comorbid depressive or anxiety disorder. The majority of patients with anxiety and depression were prescribed antidepressants. Mental health specialty visits were less frequent than medication treatment overall but most common for those with dementia only. These data suggest that specialty mental health care remains a significant unmet need for individuals with neurological disorders complicated by depression and anxiety.

Alleviating manoeuvres (sensory tricks) in cervical dystonia.

BACKGROUND: There is limited information on the phenomenology, clinical characteristics and pathophysiology of alleviating manoeuvres (AM), also called 'sensory tricks' in cervical dystonia (CD). METHODS: Individual data, collected from 10 sites participating in the Dystonia Coalition (http://clinicaltrials.gov/show/NCT01373424), included description of localisation and phenomenology of AM collected by systematic review of standardised video examinations. Analyses correlated demographic, neurologic, and psychiatric features of CD patients with or without effective AM. RESULTS: Of 154 people studied, 138 (89.6%) used AM, of which 60 (43.4%) reported partial improvement, 55 (39.8%) marked improvement, and 4 (0.03%) no effect on dystonic posture. Light touch, usually to the lower face or neck, was used by >90%. The presence or location of AM did not correlate with the severity of the dystonia. CONCLUSIONS: In this large and comprehensive study of CD, we found no clinical predictors of effective AM. Further studies of sensorimotor integration in dystonia are needed to better understand the pathophysiology of AM.

Anxiety has specific syndromal profiles in Parkinson disease: a data-driven approach.

BACKGROUND: Anxiety symptoms are common in Parkinson disease (PD). Recent evidence suggests that anxiety syndromes as encountered in clinical practice may not correspond to the DSM-IV classification of anxiety disorders. OBJECTIVE: To examine the syndromal pattern of the anxiety spectrum in a large series of patients with PD, as determined with a data-driven approach using latent class analysis (LCA). METHODS: 342 patients with PD were recruited from referrals to movement disorders or psychiatry clinics at six tertiary centers. Participants were assessed with a structured psychiatric interview and specific scales rating the severity of anxiety, depression, cognition and parkinsonism. The main outcome measure was classes of patients with a specific syndromal profile of anxiety symptoms based on LCA. RESULTS: LCA identified four classes that were interpreted as "no anxiety or depression", "episodic anxiety without depression", "persistent anxiety with depression", and "both persistent and episodic anxiety with depression". Symptoms of persistent anxiety were almost invariably associated with symptoms of depression. There were significant differences between classes in terms of history of depression and anxiety, use of psychoactive medication, and on the Mentation and Complications sections of the Unified Parkinson Disease Rating Scale. CONCLUSIONS: Patients with PD show different syndromic profiles of anxiety that do not align with the symptom profiles represented by DSM-IV anxiety disorders and major depression. Accordingly, DSM-IV criteria for anxiety disorders may not be clinically useful in PD. The different classes identified here provide empirically validated phenotypes for future research.

Transdisciplinary women's health: a call to action.

Various women's health concerns (e.g., hormonal changes, cardiovascular disease, diabetes mellitus, osteoporosis, immune deficiencies, respiratory diseases, eating disorders, substance use/abuse, sexually transmitted infections, stress, poverty, poor nutrition, and early childhood caries) are associated with oral-systemic etiologies that can either cause or form as a result of poor oral health. Nonetheless, the intersections of biological, social-behavioral, and structural factors that impact women's oral-systemic health are rarely examined. We argue for the need for transdisciplinary research, grounded in team science, for incorporating and transcending multiple discipline-specific frameworks and models to examine the complexity of women's health issues holistically across the lifespan.

Physical Violence and Aggression in Parkinson's Disease: A Systematic Review.

BACKGROUND: Physical violence and aggression (PVA), defined as behaviors with the potential to cause bodily injury, are unfortunate risks in the management of all-cause neurodegenerative dementias. While dementia in Parkinson's disease (PD) may not be evident for many years after clinical onset, neuropsychiatric disturbances occur at all stages of the disease. At issue is whether PVA in PD is associated with clinical factors that can be targets for prevention and management in the absence of a prevailing dementia syndrome. OBJECTIVE: This systematic review examined the extent to which PVA in PD without dementia is a clinically significant concern and whether it is associated with factors that could warrant proactive management. METHODS: A systematic search of 9 electronic databases used MeSH headings and equivalent terms for PD, aggression, and violence. Eligible manuscripts were original articles that were published in peer-reviewed journals and reported on adults with PD in the awake state with PVA as possible outcomes. Extracted data included study design, PD ascertainment methods and characteristics, PVA assessment methods, subject demographics, psychiatric and medical comorbidities, and pertinent results. Inciting and confounding factors were extracted from case reports. Quality assessment tools were applied in accordance with the study design (e.g., observational, qualitative, or case report). RESULTS: The search identified 10 manuscripts: 2 observational quantitative studies (total n with PD = 545), 1 qualitative study (n with PD = 20), and 7 case reports (n = 7). The observational studies suggested that PVA is less common than other neuropsychiatric disturbances, but heterogeneous methods and quality concerns prevented further conclusions. In the case reports, all patients were male, and most were early onset. In 6 of the reports, PVA occurred in the context of bilateral subthalamic nucleus deep brain stimulation. CONCLUSIONS: PVA, while relatively rare in PD, can be a significant management issue that is associated with select premorbid characteristics and antiparkinsonian motor treatments. As PVA may be under-reported, further understanding of its frequency, causes, risk factors, and outcomes would benefit from its systematic assessment, ideally using self-report and informant-based questionnaires.

Psychiatric comorbidities in dystonia: emerging concepts.

Psychiatric disorders are highly prevalent in patients with dystonia and have a profound effect on quality of life. Patients with dystonia frequently meet criteria for anxiety disorders, especially social phobia, and major depressive disorder. Deficits in emotional processing have also been demonstrated in some dystonia populations. Onset of psychiatric disturbances in patients with dystonia often precedes onset of motor symptoms, suggesting that the pathophysiology of dystonia itself contributes to the genesis of psychiatric disturbances. This article examines the hypothesis that mood and anxiety disorders are intrinsic to the neurobiology of dystonia, citing the available literature, which is derived mostly from research on focal isolated dystonias. Limitations of studies are identified, and the role of emotional reactivity, especially in the context of pain secondary to dystonia, is recognized. Available evidence underscores the need to develop dystonia assessment tools that incorporate psychiatric measures. Such tools would allow for a better understanding of the full spectrum of dystonia presentations and facilitate research on the treatment of dystonia as well as the treatment of psychiatric illnesses in the context of dystonia. This article, solicited for a special Movement Disorders issue on novel research findings and emerging concepts in dystonia, addresses the following issues: (1) To what extent are psychiatric disturbances related to the pathophysiology of dystonia? (2) What is the impact of psychiatric disturbances on outcome measures of current assessment tools for dystonia? (3) How do psychiatric comorbidities influence the treatment of dystonia? Answers to these questions will lead to an increased appreciation of psychiatric disorders in dystonia, a better understanding of brain physiology, more nuanced research questions pertaining to this population, better clinical scales that can be used to further patient management and research, and improved patient outcomes. © 2013 Movement Disorder Society.

Pharmacologic treatment of anxiety disorders in Parkinson disease.

OBJECTIVE: Neither best practices nor an evidence base for the pharmacologic treatment of anxiety in Parkinson disease (PD) has been established. This study investigated pharmacologic treatment of anxiety disorders in idiopathic PD and the associated clinical features. DESIGN: Cross-sectional. SETTING: Three community-based movement disorder neurology practices. PARTICIPANTS: 250 subjects with PD. MEASUREMENTS: Anxiety disorder diagnoses were established by consensus using a panel of six psychiatrists with expertise in geriatric psychiatry and movement disorders. Current medications were provided by the treating neurologists at the time of interview. RESULTS: Among subjects with anxiety disorders only, 53% were untreated with medications. When anxious subjects with comorbid depressive disorders were included, 70.8% were on medications effective for treatment of anxiety. Subjects with anxiety and comorbid depressive disorders were more likely to be treated for their psychiatric disturbances than subjects with anxiety disorders alone (odds ratio: 8.33), as were subjects with comorbid motor fluctuations (odds ratio: 3.65). There were no differences in the types of anti-anxiety medications used in regard to the presence of depression or motor fluctuations. CONCLUSIONS: These findings suggest that over half of nondepressed PD patients with clinically significant anxiety are untreated with medication. A better understanding of the role of clinical features associated with anxiety in PD, such as depression and motor fluctuations, may improve the recognition and treatment of anxiety disorders in this population.

Depression and Parkinson's disease: current knowledge.

Depressive disturbances are common in patients with Parkinson's disease (PD) and influence many other clinical aspects of the disease. In addition to causing inherent emotional distress, depressive disorders negatively impact quality of life, motor and cognitive deficits, functional disability, and other psychiatric comorbidities in patients with PD. Knowledge of the pathophysiology of PD depression remains limited. However, clinical studies demonstrate the efficacy of medications and psychotherapies for PD depression, underscoring the importance of their timely detection and concerted management.

Problems With Medium-Sized Joints: Wrist Conditions.

Common wrist conditions include fractures and other injuries, osteoarthritis, radial epiphysitis, joint instability, de Quervain tenosynovitis, carpal tunnel syndrome, ganglion cyst, and ulnar neuropathy. The initial history and physical examination, with particular focus on the anatomic structures of the wrist, can narrow the differential diagnosis. Magnetic resonance imaging study can be used to identify soft tissue masses and occult osseous processes, particularly with scaphoid fractures. Computed tomography scan is useful in cases of bony abnormalities, high clinical suspicion of occult fracture, and surgical planning. Musculoskeletal ultrasonography can help identify soft tissue injuries, synovitis, or edema. It also can assess for nerve pathology, such as increased median nerve surface area in carpal tunnel syndrome. Management of common wrist fractures, such as distal radius, carpal, and scaphoid fractures, includes nonsurgical and surgical options, immobilization, and referral for further management or surgical consultation. Other wrist conditions, including overuse conditions such as carpometacarpal osteoarthritis or radial epiphysitis, can be managed conservatively initially. Ganglion cysts can be managed with immobility and rest initially, or aspiration or surgical excision. Ulnar neuropathy is the result of local compression of the ulnar nerve at the level of the carpal bones. It typically is managed with activity modification and splinting.