User-centred design, validation and clinical testing of an anti-choking mug for people with Parkinson's disease.

Oropharyngeal dysphagia, or difficulty initiating swallowing, is a frequent problem in people with Parkinson's disease (PD) and can lead to aspiration pneumonia. The efficacy of pharmacological options is limited. Postural strategies, such as a chin-down manoeuvre when drinking, have had some degree of success but may be difficult for people who have other limitations such as dementia or neck rigidity, to reproduce consistently. Using a user-centred design approach and a multidisciplinary team, we developed and tested an anti-choking mug for people with PD that helps angle the head in the optimum position for drinking. The design reflected anthropometric and ergonomic aspects of user needs with features including regulation of water flow rate and sip volume, an inner slope, a thickened handle and a wide base, which promoted a chin-down posture when used. Prototype testing using digital technology to compare neck flexion angles (the primary outcome), plus clinical outcomes assessed using standard tools (Swallowing Clinical Assessment Score in Parkinson's Disease (SCAS-PD) and Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Parts II and III), found significant improvements in a range of parameters related to efficient swallowing and safe drinking when using the anti-choking mug versus a sham mug.

Bedside clinical assessment of patients with common upper limb tremor and algorithmic approach.

The diagnostic approach for patients with tremor is challenging due to the complex and overlapping phenotypes among tremor syndromes. The first step in the evaluation of tremor is to identify the tremulous movement and exclude the tremor mimics. The second step is to classify the tremor syndrome based on the characteristics of tremor from historical clues and focused examination (Axis 1). Comprehensive tremor examinations involve the assessment of tremor in different conditions (rest, action or mixed, position or task-specific), distribution of tremor (upper limb, lower limb, head, jaw), positive signs for functional tremor (FT) if suspected (distractibility, entrainment, co-contraction), and associated neurological signs including parkinsonism, dystonic posture, cerebellar/brainstem signs, neuropathy, and cognitive impairment. A pivotal feature in this step is to determine any distinct feature of a specific isolated or combined tremor syndrome. In this review, we propose an algorithm to assess upper limb tremors. Ancillary testing should be performed if clinical evaluation is unclear. The choice of investigation depends on the types of tremors considered to narrow down the spectrum of etiology (Axis 2). Laboratory blood tests are considered for acute onset and acute worsening of tremors, while structural neuroimaging is indicated in unilateral tremors with acute onset, nonclassical presentations, and a combination of neurological symptoms. Neurophysiological study is an important tool that aids in distinguishing between tremor and myoclonus, etiology of tremor and document specific signs of FT. Treatment is mainly symptomatic based depending on the etiology of the tremor and the patient's disabilities.

Fluorouracil-induced leukoencephalopathy mimicking neuroleptic malignant syndrome: a case report.

BACKGROUND: Fluorouracil-induced leukoencephalopathy is a rare complication and has been reported to present as confusion, oculomotor abnormality, ataxia, and parkinsonism; however, there is no previous report of a presentation mimicking neuroleptic malignant syndrome. Acute cerebellar syndrome may occur, which can be explained by the extremely high accumulation of the drug in the cerebellum. However, presentation mimicking neuroleptic malignant syndrome similar to our case has never been reported. CASE PRESENTATION: Here, we describe a 68-year-old Thai male presenting with advanced-stage cecal adenocarcinoma, as well as symptoms and signs indicative of neuroleptic malignant syndrome. He received two doses of intravenous metoclopramide 10 mg 6 hours before his symptoms occurred. Magnetic resonance imaging scan revealed signal hyperintensity within the bilateral white matter. Further evaluation showed that his thiamine level was extremely low. Thus, he was diagnosed with fluorouracil-induced leukoencephalopathy mimicking neuroleptic malignant syndrome. The concomitant fluorouracil-induced thiamine deficiency eventually leads to rapid depletion of thiamine and was considered a risk factor for fluorouracil-induced leukoencephalopathy. CONCLUSION: Fluorouracil-induced leukoencephalopathy is believed to be caused by insult causing mitochondrial dysfunction. However, the exact mechanism remains unknown, but our finding suggests that thiamine deficiency plays a crucial role in fluorouracil-induced leukoencephalopathy. Diagnosis is usually delayed due to a lack of clinical suspicion and results in significant morbidity requiring unnecessary investigations.

Evaluation of Psychometric Properties of Thai Version Telehealth Usability Questionnaire (T-TUQ).

This cross-sectional validation study aimed to translate, cross-culturally adapt, and investigate the psychometric properties of a Thai version of the Telehealth Usability Questionnaire (T-TUQ). Two hundred and ten Thai participants, mean age of 61.2±15.2 years, were recruited from three specialty clinics: 50 (23.8%) hematology, 70 (33.3%) movement disorders, and 90 (42.9%) general neurology. The T-TUQ was translated from the original English version to produce a Thai language version. Back translation and pilot cognitive interviews were completed. All five subscales (usefulness, ease of use, effectiveness, reliability, and satisfaction) showed excellent internal consistency (alpha >0.80), displayed by Cronbach's alpha coefficient of 0.83, 0.94, 0.86, 0.83, and 0.92, respectively. For construct validity, exploratory factor analysis revealed two dimensions from eigenvalues and scree plot, defined as utility and accessibility subscales. In conclusion, the T-TUQ could be a reliable and valid instrument to evaluate the usability of telehealth with a Thai population.

Residual effects of combined vibratory and plantar stimulation while seated influences plantar pressure and spatiotemporal gait measures in individuals with Parkinson's disease exhibiting freezing of gait.

Introduction: Combined plantar pressure and vibratory stimulation has been shown to decrease freezing of gait (FOG) episodes and improve spatiotemporal gait parameters compared to single stimulation in Parkinson's disease (PD) patients with FOG. However, the effect of combined plantar stimulations on plantar pressure analysis has never been explored. Methods: Forty PD patients with frequent FOG were allocated to either FOG shoes embedded with a 100 Hz vibratory stimulation at the Achilles tendons and a soft thickened silicone pad at the hallux and sole, or sham shoes with a non-working vibratory motor and a flat non-pressure silicone pad (20 patients per arm) while seated for 96 s. The objective gait and plantar pressure analysis were measured immediately after the stimulation. Outcomes included the normalized percentage of changes in percent FOG (%FOG) and plantar pressure in the heel-strike and push-off phase that were compared between pre- and post-stimulations. Results: The FOG shoes group showed significantly decreased %FOG (81.5 ± 28.9% vs. 6.8 ± 22.1%, p < 0.001), plantar pressure in the heel-strike (47.8 ± 43.7% vs. 4.3 ± 9.8%, p < 0.001), plantar pressure in the push-off (57.7 ± 59.6% vs. 6.2 ± 11.6%, p < 0.001), force time integral (FTI) (40.9 ± 32.5% vs. 6.6 ± 17.3%, p < 0.001), and decreased heel contact time (19.3 ± 12.3% vs. 22.7 ± 32.5%, p < 0.001) when compared to the sham group. There was a strong negative correlation between %FOG and peak plantar pressure (r = -0.440, p = 0.005), plantar pressure in the heel-strike (r = -0.847, p < 0.001). Conclusion: Our study demonstrated that the FOG shoe could decrease FOG episodes by improving the heel-strike pressure, toe push-off and normalized heel-to-toe plantar pressure, suggesting that modification inputs from the peripheral sensory systems might significant improvement in FOG in PD.

Vibratory and plantar pressure stimulation: Steps to improve freezing of gait in Parkinson's disease.

INTRODUCTION: Freezing of gait (FOG) is a devastating symptom that develops in patients with advanced Parkinson's disease (PD) and is often unresponsive to pharmacological treatment. Recent research suggests that FOG may result from dysfunctional plantar peripheral sensory systems. The impact of combined plantar pressure and vibratory stimulation over vibratory or pressure alone on FOG remains unexplored. METHODS: PD patients with FOG were randomised into four groups and treated with combined vibratory and pressure stimulation, vibratory stimulation alone, pressure stimulation alone, or controls (no stimulation). Vibratory stimulation targeted both Achilles' tendons. Simultaneous bilateral pressure stimulation was applied to the first hallux, first metatarsal bone, and the sole. The primary outcome included normalized percent changes in percent FOG measured both pre- and immediately post-stimulation. Other outcomes including clinical rating scale, response to questionnaires, number and duration of freezing episodes, and spatiotemporal gait parameters at pre- and freezing episodes were also explored. RESULTS: Sixty PD patients participated in the study. Patients who were treated with combined vibratory and pressure stimulation responded with significant decreases in normalized percent changes of percent FOG (62.75 ± 25.54%, p < 0.001) compared with those treated with vibration alone (11.38 ± 8.29%, p < 0.001), pressure alone (15.15 ± 16.18%, p < 0.001), or controls (8.59 ± 16.85%, p < 0.001). CONCLUSION: Our study demonstrated the benefit of combined vibratory and pressure stimulation on FOG suggesting that this strategy might be developed as a novel treatment modality for PD patients with FOG.

Management of dysphagia and gastroparesis in Parkinson's disease in real-world clinical practice - Balancing pharmacological and non-pharmacological approaches.

Gastrointestinal (GI) issues are commonly experienced by patients with Parkinson's disease (PD). Those that affect the lower GI tract, such as constipation, are the most frequently reported GI problems among patients with PD. Upper GI issues, such as swallowing dysfunction (dysphagia) and delayed gastric emptying (gastroparesis), are also common in PD but are less well recognized by both patients and clinicians and, therefore, often overlooked. These GI issues may also be perceived by the healthcare team as less of a priority than management of PD motor symptoms. However, if left untreated, both dysphagia and gastroparesis can have a significant impact on the quality of life of patients with PD and on the effectiveness on oral PD medications, with negative consequences for motor control. Holistic management of PD should therefore include timely and effective management of upper GI issues by utilizing both non-pharmacological and pharmacological approaches. This dual approach is key as many pharmacological strategies have limited efficacy in this setting, so non-pharmacological approaches are often the best option. Although a multidisciplinary approach to the management of GI issues in PD is ideal, resource constraints may mean this is not always feasible. In 'real-world' practice, neurologists and PD care teams often need to make initial assessments and treatment or referral recommendations for their patients with PD who are experiencing these problems. To provide guidance in these cases, this article reviews the published evidence for diagnostic and therapeutic management of dysphagia and gastroparesis, including recommendations for timely and appropriate referral to GI specialists when needed and guidance on the development of an effective management plan.