Deep brain stimulation targeting the Globus pallidus internus for Parkinson's disease and Tourette syndrome.

We present a case with co-existing Parkinson's disease and Tourette syndrome. Patient takes aripiprazole for Tourette syndrome, which unfortunately worsens his parkinsonian symptoms. We placed deep brain stimulation targeting the Globus pallidus internus. Strikingly, his parkinsonian motor symptoms and his tics are both well controlled with deep brain stimulation.

Epidural Spinal Cord Stimulation: A Novel Therapy in the Treatment of Restless Legs Syndrome.

BACKGROUND: We report a unique finding of a patient whose restless legs syndrome (RLS) symptoms abated after the placement of a spinal cord stimulator for chronic neuropathic pain. RLS is a common disorder, with many patients unable to find sufficient relief from their symptoms. CASE DESCRIPTION: A patient diagnosed with neuropathic pain who also suffered from RLS symptoms despite medication therapy underwent implantation of a spinal cord stimulator after a successful trial. This patient was interviewed formally about his RLS symptoms immediately before his procedure and at 6 weeks, 6 months, and 2.5 years after the procedure. The patient also completed the International Restless Legs Syndrome Scale questionnaire to objectively quantify the severity of his symptoms. Finally, the patient kept a 5-day journal detailing when the stimulator was in use. The patient reported subjective symptomatic improvement in his RLS symptoms with improved sleep quality and quantity, in addition to improvement in his back pain. The patient's score on the International Restless Legs Syndrome Scale improved after implantation from 33 to 0 on a 40-point scale. Moreover, when asked to keep a journal record of his stimulator use, the patient noted that he only used the stimulator before going to bed to help his RLS symptoms and no longer required any medication for his previous RLS symptoms. CONCLUSIONS: Epidural stimulation may be an additional, alternative, or novel therapy in the treatment of RLS.

Phase I/II randomized trial of aerobic exercise in Parkinson disease in a community setting.

OBJECTIVES: To (1) investigate effects of aerobic walking on motor function, cognition, and quality of life in Parkinson disease (PD), and (2) compare safety, tolerability, and fitness benefits of different forms of exercise intervention: continuous/moderate intensity vs interval/alternating between low and vigorous intensity, and individual/neighborhood vs group/facility setting. METHODS: Initial design was a 6-month, 2 × 2 randomized trial of different exercise regimens in independently ambulatory patients with PD. All arms were required to exercise 3 times per week, 45 minutes per session. RESULTS: Randomization to group/facility setting was not feasible because of logistical factors. Over the first 2 years, we randomized 43 participants to continuous or interval training. Because preliminary analyses suggested higher musculoskeletal adverse events in the interval group and lack of difference between training methods in improving fitness, the next 17 participants were allocated only to continuous training. Eighty-one percent of 60 participants completed the study with a mean attendance of 83.3% (95% confidence interval: 77.5%-89.0%), exercising at 46.8% (44.0%-49.7%) of their heart rate reserve. There were no serious adverse events. Across all completers, we observed improvements in maximum oxygen consumption, gait speed, Unified Parkinson's Disease Rating Scale sections I and III scores (particularly axial functions and rigidity), fatigue, depression, quality of life (e.g., psychological outlook), and flanker task scores (p < 0.05 to p < 0.001). Increase in maximum oxygen consumption correlated with improvements on the flanker task and quality of life (p < 0.05). CONCLUSIONS: Our preliminary study suggests that aerobic walking in a community setting is safe, well tolerated, and improves aerobic fitness, motor function, fatigue, mood, executive control, and quality of life in mild to moderate PD. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that in patients with PD, an aerobic exercise program improves aerobic fitness, motor function, fatigue, mood, and cognition.

Juvenile parkinsonism: epidemiology, diagnosis and treatment.

Juvenile parkinsonism, with onset prior to age 21 years, is a relatively rare syndrome. It is caused by a group of heterogeneous entities that can present with a clinical picture similar to idiopathic Parkinson's disease or manifest parkinsonism as part of a spectrum of other signs. Diagnostic testing is guided by the presenting symptoms and aimed at uncovering potentially reversible and/or treatable causes. If an underlying condition is found, treatment is tailored accordingly. Otherwise, treatment is symptomatic and relies on medications commonly employed to treat idiopathic Parkinson's disease. Juvenile parkinsonism patients tend to be plagued by treatment-induced complications, so caution must be employed.

Ipratropium bromide spray as treatment for sialorrhea in Parkinson's disease.

Sialorrhea is a significant problem in advanced Parkinson's disease (PD). Current treatment options include systemic anticholinergics which frequently cause side effects. We hypothesized that sublingual application of ipratropium bromide spray, an anticholinergic agent that does not cross the blood brain barrier, may reduce drooling without systemic side effects. We performed a randomized, double blind, placebo-controlled, crossover study in 17 subjects with PD and bothersome drooling. Patients were randomized to receive ipratropium bromide or placebo (one to two sprays, maximum of four times per day) for 2 weeks followed by a 1 week washout and crossover for further 2 weeks of treatment. The primary outcome was an objective measure of weight of saliva production. Secondary outcomes were subjective rating of severity and frequency of sialorrhoea using home diaries, United Parkinson's Disease Rating Scale (UPDRS) part II salivation subscore, parkinsonian disability using UPDRS, and adverse events. Ipratropium bromide spray had no significant effect on weight of saliva produced. There was a mild effect of treatment on subjective measures of sialorrhea. There were no significant adverse events. Ipratropium bromide spray was well tolerated in subjects with PD. Although it did not affect objective measures of saliva production, further studies in parkinsonism may be warranted.