Shoulder Dysfunction in Parkinson Disease: Review of Clinical, Imaging Findings and Contributing Factors.

This study aimed to review shoulder clinical and imaging findings in Parkinson's disease (PD), focusing on the significance of timely diagnosis and management of shoulder dysfunction in PD for the prevention of shoulder-related complications. A bibliographical search was employed, using "Parkinson's" and "Shoulder Dysfunction" as keywords. A Magnetic Resonance Imaging, twenty clinical and three US studies were selected as relevant to shoulder dysfunction in PD. Shoulder pain, frozen shoulder and arm swing asymmetry are the most prevalent clinical findings that may antedate cardinal PD symptoms. Supraspinatus tendon thickening or tearing, adhesive capsulitis, acromioclavicular changes, bursa and joint effusion are common shoulder MRI or US-detected abnormalities in mild or severe PD stages. Fractures due to falls or osteoporosis are secondary shoulder pathologies. Higher ipsilateral Unified Parkinson's Disease Rated Scale (UPDRS) scores, rigidity, tremor, and bradykinesia are associated with frozen shoulder. Disease duration, rigidity, and falls are contributing factors for tendon tears, adhesive capsulitis, and fractures respectively. When common symptoms, such as pain and frozen shoulder are unaccounted for by orthopedic or other local primary pathology, they might indicate underlying early PD. Timely diagnosis and appropriate early management of PD may, in turn, help delay or prevent shoulder-related complications.

Image analysis can reliably quantify median nerve echogenicity and texture changes in patients with carpal tunnel syndrome.

OBJECTIVE: To study the ability of image analysis measures to quantify echotexture changes of median nerve in order to provide a complementary diagnostic tool in CTS. METHODS: Image analysis measures (gray level co-occurrence matrix (GLCM), brightness, hypoechoic area percentage using max entropy and mean threshold) were calculated in normalized images of 39 (19 younger and 20 older than 65y) healthy controls and 95 CTS patients (37 younger and 58 older than 65y). RESULTS: Image analysis measures were equivalent or superior (older patients) to subjective visual analysis. In younger patients, GLCM measures showed equivalent diagnostic accuracy with cross sectional area (CSA) (Area Under Curve (AUC for inverse different moment = 0.97). In older patients all image analysis measures showed similar diagnostic accuracy to CSA (AUC for brightness = 0.88). Moreover, they had abnormal values in many older patients with normal CSA values. CONCLUSIONS: Image analysis reliably quantifies median nerve echotexture alterations in CTS and offers similar diagnostic accuracy to CSA measurement. SIGNIFICANCE: Image analysis may offer added value to existing measures in the evaluation of CTS, especially in older patients. Its clinical implementation would require incorporation of mathematically simple software code for online nerve image analysis in ultrasound machines.

Application of the AT(N) and Other CSF Classification Systems in Behavioral Variant Frontotemporal Dementia.

BACKGROUND: Patients with a frontotemporal lobar degeneration (FTLD) usually manifest with behavioral variant frontotemporal dementia (bvFTD). Alzheimer's disease (AD) may also manifest with a predominant behavioral-dysexecutive syndrome, similar to bvFTD. Cerebrospinal fluid (CSF) biomarkers, such as total tau (τT), phosphorylated tau (τP-181) and amyloid beta with 42 amino-acids (Aß42), can predict AD pathology in vivo. The aim of this study was to compare the τT/Aß42 and τP-181/Aß42 ratios, the BIOMARKAPD/ABSI criteria and the AT(N) classification system in a cohort of bvFTD patients. METHODS: A total of 105 bvFTD patients (21 possible bvFTD; 20%) with CSF data, examined from 2008 to 2022, were included. Seventy-eight AD patients and 62 control subjects were included. The CSF biomarkers were measured with Innotest (2008-2017 subcohort) and EUROIMMUN (2017-2022 subcohort) ELISAs. RESULTS: Depending on the classification system, 7.6 to 28.6% of bvFTD had an AD biochemical profile. The τT/Aß42 and τP-181/Aß42 ratios classified more patients as AD compared to the BIOMARKAPD/ABSI and AT(N) systems. The patients with possible bvFTD had higher frequencies of AD compared to the probable bvFTD patients. CONCLUSIONS: The four classification criteria of CSF AD biomarkers resulted in differences in AD allocation in this bvFTD cohort. A consensus on the optimal classification criteria of CSF AD biomarkers is pivotal.

Calculating Turns/Amplitude peak ratio of EMG interference pattern by using logistic curve fitting.

The aim of the study was to test whether logistic curve fitting (LCF) of Turns = f(Amplitude) plots of single muscle contractions can provide a reliable alternative method for peak-ratio calculation. EMG signals from 74 biceps and 62 triceps contractions were analyzed by applying LCF to Turns = f(Amplitude) plots. Peak-ratio (peak-ratio2) could then be calculated as the point of the fitted line with the highest Turn/Amplitude value. LCF yielded R2 values > 0.95 in the vast majority of contractions studied (68/74 biceps and 53/62 triceps). Peak-ratio2 values had a very strong linear relationship with the corresponding values calculated by the traditional method (peak-ratio1) in both normal and neurogenic conditions. Furthermore, ROC curve analysis showed that peak-ratio1 and peak-ratio2 had similar AUC values. Based on the LCF equation, peak-ratio = T2*(p - 1)/A0*p*(p - 1)1/p. Therefore, peak-ratio is proportional to the maximum number of turns (T2), positively correlated to the rate of turns' increment at the midpoint of the curve (p) and negatively correlated to the mean amplitude at the midpoint of the curve (A0). A0 is the variable that best discriminates between normal and neurogenic conditions. We provide an alternative method for peak-ratio calculation and show the variables that influence this sensitive marker of neurogenic disease.

The diagnostic accuracy of high-resolution ultrasound in screening for carpal tunnel syndrome and grading its severity is moderated by age.

OBJECTIVE: To assess the effect of age on the accuracy of high-resolution ultrasound (HRUS) in the diagnosis and grading of carpal tunnel syndrome (CTS). METHODS: Patients with symptoms and signs of CTS (N = 527 wrists) were evaluated using electrodiagnostic studies (EDx) for CTS diagnosis and grading. Median nerve cross-sectional areas at carpal tunnel inlet (CSA) and at forearm level were measured by HRUS and the ratio of these values was calculated (WFR). Healthy controls underwent identical testing (N = 122 wrists). HRUS accuracy was assessed against the EDx standard by Receiver Operator Characteristic (ROC) curve analysis. RESULTS: In patients >65 y with moderate and severe CTS, disease-related increases in CSA and WFR were negatively correlated with increasing age. Subjects were grouped by age into younger (<65 y) and older (≥65 y). The c-statistics for CSA and WFR respectively were: For CTS diagnosis, younger group: 0.94 and 0.96 (excellent); older group: 0.85 and 0.86 (satisfactory). For CTS grading, younger group: differentiating mild CTS from controls: 0.90 and 0.92 (excellent); mild from moderate: 0.79 and 0.74 (satisfactory); moderate from severe: 0.82 and 0.78 (satisfactory). For CTS grading, older group: differentiating mild CTS from controls: 0.83 and 0.83 (satisfactory); mild from moderate: 0.53 and 0.61 (poor); moderate from severe: 0.65 and 0.53 (poor). CONCLUSIONS: For subjects aged <65 y, HRUS accuracy is excellent in CTS diagnosis and satisfactory in grading. For older subjects, accuracy is satisfactory in diagnosis but not in grading. SIGNIFICANCE: HRUS for CTS has diagnostic limitations selectively in older individuals.

Defining Neuropsychiatric Inventory scale differences across frontotemporal dementia syndromes.

AIM: The aim of this study was to assess the ability of Neuropsychiatric Inventory (NPI) scale profiles to differentiate between distinct frontotemporal dementia (FTD) subtypes. METHODS: The NPI was used to assess 311 older patients who had been clinically diagnosed with FTD. FTD subtypes included behavioural variant FTD (bvFTD, n = 121), primary progressive aphasia (semantic variant (n = 69), non-fluent agrammatic variant (n = 31), and logopenic variant (n = 0)), FTD-motor neuron disease (n = 4), progressive supranuclear palsy (n = 43), and corticobasal syndrome (n = 43). Total NPI score and scores for each NPI item were correlated across the distinct FTD subtypes. RESULTS: Patients with bvFTD showed significantly greater impairment on their total NPI score than patients with corticobasal syndrome (P < 0.001), non-fluent agrammatic variant primary progressive aphasia (P < 0.001), progressive supranuclear palsy (P = 0.002), and semantic variant primary progressive aphasia (P = 0.010). Aggressiveness, euphoria, apathy, disinhibition, irritability, aberrant motor behaviours, and appetite disturbance were significantly higher in bvFTD than in the other subgroups. The lowest NPI scores were generally shown among those with CBS. However, NPI total and specific item values overlapped among the subtypes. CONCLUSIONS: Patients with bvFTD showed significantly greater neuropsychiatric dysfunction than those with the other FTD subtypes, as measured by the NPI scale. In contrast, patients with corticobasal syndrome had a comparatively healthier profile. Therefore, differential diagnosis among the FTD subtypes may be guided by the NPI, although the subtype is unlikely to be confirmed on the basis of NPI alone.

A strong linear relationship between Turns/Amplitude peak ratio and ratio at maximal effort.

In EMG interference pattern analysis, the peak value of turns to mean amplitude ratio [peak(T/A)] is an established clinically significant marker, but its calculation requires specific software available only in few EMG apparatuses. On the contrary, the turns to mean amplitude ratio obtained at maximal muscle contraction (T/Amax) is easily calculated but less well standardized. We aimed to quantitatively assess the association between T/Amax and peak(T/A). Data were derived from 642 muscle contractions (Nc) from 270 consecutive patients (Np) who underwent EMG at our laboratory (software Dantec Keypoint, QEMG) from May 2015 to September 2016 and had interference patterns obtained from at least one of the following muscles: triceps-lateral head, brachioradialis, extensor digitorum communis and biceps. Statistics were calculated separately for normal and neurogenic muscles. Peak(T/A) was calculated by the built-in "peak ratio" function. T/Amax was calculated by the built-in Interference Pattern analysis function. The ratio with the highest amplitude was selected as T/Amax. Linear regression models provided high Pearson correlation coeffficientscoefficients (R) between peak(T/A) and T/Amax for all 4 muscles, normal or neurogenic, except a subgroup of biceps in patients aged <40y. Specifically, R were: (A) triceps normal 0.79 (Nc = 99), neurogenic 0.83 (Nc = 50) (B) brachioradialis normal 0.81 (Nc = 84), neurogenic 0.78 (Nc = 66) (C) extensor digitorum communis normal 0.72 (Nc = 92), neurogenic 0.73 (Nc = 61) (D) biceps (age > 40y) normal 0.77 (Nc = 77), neurogenic 0.67 (Nc = 62). We conclude that T/Amax has a strong linear association with peak(T/A) and, therefore, the former may be further investigated as a potentially useful quantitative diagnostic marker, especially in cases where the latter is not available.

The effect of cortical and subcortical lesions on spontaneous expression of memory-encoded and emotionally infused information: Evidence for a role of the ventral stream.

The ventral stream of language processing has been implicated in the spontaneous expression of memory-encoded and emotionally infused information. The present study investigated whether left hemispheric lesions in post-stroke right-handed aphasic patients may be selectively associated with specific language functions. Speech rate was assessed with two tasks, one based on autobiographical memory of an emotionally infused event (stroke story narration) and the other based on information that is visually available at the time of speech generation ("cookie theft" picture description). CT and/or MRI scans were obtained for each patient and lesions located in 16 regions of the left hemisphere were identified and coded. The total number of cortical and subcortical areas affected served as a measure of lesion extent. While mean speech rates were similar across conditions, there were different patterns of association between each index and specific lesion sites. Non-parametric quantile regression statistical models constructed to assess dependence of both speech rate indices on each lesion locus indicated that the speech rate in the stroke story had significant inverse associations with total number of lesioned areas, as well as lesions in the inferior frontal gyrus and the external/extreme capsule region. The cookie theft speech rate had significant inverse associations with total number of lesioned areas as well as lesion in the inferior frontal gyrus, but not with the external/extreme capsule region. In sum, integrity of the extreme/external capsule region appears to be important selectively for the Stroke Story task, supporting the hypothesis that the ventral stream plays a central role in spontaneous expression of memory-encoded and emotionally infused information.

Unilateral suppression of P/N13' potential amplitude in young patients with persistent numbness due to cervical monoradiculopathy. A case-control study.

OBJECTIVE: The utility of Dermatomal Somatosensory Evoked Potentials (DSEPs) in the diagnostic workup of suspected cervical monoradiculopathy has been limited by significant overlap between measurements obtained from affected versus unaffected roots. In a case-control study, we explored whether, under certain conditions, asymmetry in DSEP parameters may offer significant help in the diagnosis of monoradiculopathy. METHODS: DSEPs were obtained bilaterally from patients with persistent (age range 33-55, n = 10) or intermittent (age range 31-55, n = 7) unilateral sensory symptoms of less than one month duration due to MRI-confirmed cervical monoradiculopathy. DSEPs were also obtained bilaterally from aged-matched asymptomatic volunteers (age range 31-54, n = 8) and older asymptomatic volunteers (age range 57-77, n = 8). Amplitude and latency of the P/N13' potential (negative peak at 13 ms) were measured. RESULTS: In all ten patients with persistent symptoms, the P/N13' amplitude ratio, defined as P/N13' amplitude on the symptomatic side divided by P/N13' amplitude on the contralateral asymptomatic side, ranged between 0.0 and 0.50 (unilateral suppression). In all seven patients with intermittent symptoms, P/N13' amplitude ratios ranged between 0.60 and 1.00. In all age-matched asymptomatic controls, P/N13' amplitude ratio (side with lower divided by side with higher amplitude) was always at least 0.80. Among older asymptomatic subjects, DSEPs had inconsistent characteristics. CONCLUSIONS: Cervical monoradiculopathy with persistent numbness in young patients (aged up to 55 years) is very strongly associated with unilateral suppression of P/N13' DSEP amplitude. No significant asymmetry is observed in cases of monoradiculopathy with intermittent numbness. SIGNIFICANCE: In young patients with unilateral upper extremity persistent sensory complaints, DSEP amplitude asymmetry, as quantified by the P/N13' ratio, may offer significant help in the diagnosis of monoradiculopathy.

Photophobia in primary headaches, in essential blepharospasm and in major depression.

OBJECTIVES: Although photophobia is a well-known symptom in various disorders, it has rarely been studied explicitly and its definition in a clinical setting can be somewhat elusive. Here, we assessed photophobia with a common psychometric tool in different conditions, in which light intolerance is considered part of the syndrome. PATIENTS AND METHODS: A prospective study was undertaken in patients with migraine (MH), cluster headache (CH), tension-type headache (TH), essential blepharospasm (BS) and major depression (MD). Photophobia was assessed by the photophobia questionnaire (range 0-8). Symptom severity was measured in each patient group with appropriate scales. Finally, depression was assessed explicitly in each condition. RESULTS: Hundred and six subjects met the inclusion criteria (MH: 27, CH: 21, TH: 20, BS: 18, MD: 20). Photophobia scores differed between patient groups, with migraineurs showing the highest (6.63) and TH patients the lowest (2.10) scores (ranking: MH, BS, CH, MD and TH). Symptom severity as well as depression had little, if any, influence on the degree of photophobia. DISCUSSION: Photophobia is a core symptom of migraine but also constitutes a feature of other neurological conditions. The relative independence from other, disease-specific features, suggests that photophobia is a rather autonomous symptom.

Motor and Non-motor Features: Differences between Patients with Isolated Essential Tremor and Patients with Both Essential Tremor and Parkinson's Disease.

BACKGROUND: Patients with essential tremor (ET) who develop Parkinson's disease (PD) (i.e., ET→PD) may differ with respect to motor features (MFs) and non-motor features (NMFs) from patients with isolated ET. Few studies have assessed this issue. METHODS: In this retrospective chart review, we analyzed data on MFs and NMFs of 175 patients, including 54 ET→PD and 121 ET, actively followed in the Athens University 1st Neurology Department. RESULTS: Significantly more ET→PD than ET patients reported asymmetric tremor at ET onset (68.5% vs. 14.9%, p<0.001). Significantly more ET than ET→PD patients had head tremor (43.5% vs. 13.2%, p<0.001) and cerebellar signs (41.3% vs. 9.3%, p<0.001). More ET than ET→PD patients reported hearing impairment (65.3% vs. 28.3%, p<0.001) and restless legs syndrome (34.8% vs. 3.7%, p<0.001). Conversely, a larger proportion of ET→PD than ET patients reported rapid eye movement behavior disorder (51.9% vs. 10.0%, p<0.001), constipation (67.9% vs. 36.4%, p<0.001), and olfactory dysfunction (83.3% vs. 36.4%, p<0.001). DISCUSSION: The subset of ET→PD patients may have distinct MFs and NMFs that should be assessed further for the possible predictive value for the emergence of PD.

Dietary and lifestyle variables in relation to incidence of Parkinson's disease in Greece.

Identification of dietary and lifestyle variables associated with the development of Parkinson's disease (PD) may offer pathogenetic clues and prevention opportunities. In a population-based prospective cohort study, 26,173 participants in the EPIC-Greece cohort had sociodemographic, anthropometric, medical, dietary and lifestyle variables ascertained at enrolment and periodically reassessed with follow-up contacts. Based on these data, subjects were screened as possible PD cases if they (1) reported either a medical diagnosis of PD or use of anti-PD drugs and (2) did not report preceding causes of secondary parkinsonism. For diagnostic validation, possible incident PD cases were assessed by a focused 3-item telephone questionnaire. Cox proportional hazards regression was used to evaluate associations between potential predictors and incident PD. The main multivariate model included gender, age, marital status, schooling years, farming occupation, smoking status, caffeinated coffee, body mass index, physical activity and energy intake. Additional models included all above variables plus one dietary item at a time. Incidence rate adjusted to the European population was 16.9 per 100,000 person-years. In multivariate models, incident PD exhibited strong positive association with consumption of milk, but not cheese or yoghurt. This finding may help narrow down the search for potential dairy product components with a facilitatory role in PD. Concerning other dietary components, inverse association was found between polyunsaturated fat intake and incident PD. Also, inverse association was found with tobacco smoking, in line with previous studies, but not with caffeine.

Lamotrigine withdrawal may worsen RBD symptoms.

BACKGROUND: Rapid eye movement (REM) behavior disorder (RBD) is a rapid eye movement parasomnia, which in its symptomatic type could be induced by the introduction or the discontinuation of several drugs and substances. No references for antiepileptic drugs and especially for lamotrigine are known regarding pharmacologically induced RBD. CASE REPORT: We report a case of a 68-year-old man already suffering from RBD, who developed very brief episodes of epigastric discomfort followed by impaired consciousness and was given a diagnosis of epilepsy. Lamotrigine was started at 25 mg/d, reached a maximum of 100 mg/d after 2 months and was retained at this dose for 1 more month. During this period there was a slight decrease in the episodes of impaired consciousness and no appreciable changes in the frequency and intensity of RBD symptomatology. Immediately following the abrupt discontinuation of lamotrigine, RBD symptomatology was severely aggravated, with dreams becoming more vivid and frightening and occurring almost every night. RBD symptomatology gradually subsided over 2 months, reaching levels comparable to those before lamotrigine. The impaired consciousness episodes remained unaffected and were considered to be nonepileptic. CONCLUSIONS: Our findings suggest that abrupt withdrawal of lamotrigine may worsen symptoms of comorbid idiopathic RBD.