Assessment of patients with functional neurologic disorders.

We describe an overall approach and structure to the clinical assessment of the patient with a functional neurologic disorder. Whilst the primary purpose of the assessment is to make a diagnosis and develop a treatment plan, we believe the assessment also plays a key role in treatment in its own right, as it sets a tone and context for future clinical interactions. We aim to set up an atmosphere of collaboration based on taking the patient's problems seriously, and emphasizing that all facets of the patient's presentation - physical, psychologic, and social - are of importance. Patients with functional disorders can be perceived as difficult to help and yet with the correct approaches we believe the consultation can be much more satisfying for both patient and doctor. Finally, we discuss and list some of the common diagnostic pitfalls in the assessment of functional neurologic disorders, looking at features that lead to erroneous diagnosis of neurologic disease (such as old age, la belle indifférence, and lack of psychiatric comorbidity) and an erroneous diagnosis of a functional disorder (such as "bizarre" gait in stiff-person syndrome).

Short and valid assessment of apraxia in Parkinson's disease.

BACKGROUND: Valid assessment of apraxia in usually non-apraxic Parkinson's disease helps to delineate atypical parkinsonism frequently associated with apraxia. Furthermore, in a subgroup of late Parkinson's disease apraxia, typically the ideomotor subtype, may gradually superimpose onto parkinsonian motor symptoms contributing to defective manual skill. Here we evaluate the utility of a brief, standardized test, the apraxia screen of TULIA (AST). METHODS: Seventy five Parkinson's disease patients were tested with the AST. Parkinsonian motor deficits were measured using Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part III and difficulties in activities of daily living (ADL) by modified MDS-UPDRS part II (eating, dressing, personal hygiene, and writing). RESULTS: No association was found between the AST and MDS-UPDRS part III, indicating that AST discriminates well (discriminative validity) between apraxia and parkinsonism. Furthermore, AST was associated with ADL and Hoehn & Yahr stage (convergent validity). CONCLUSIONS: AST is a short and valid test to rule out or detect apraxia in Parkinson's disease.

Assessment: Botulinum neurotoxin for the treatment of movement disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

OBJECTIVE: To perform an evidence-based review of the safety and efficacy of botulinum neurotoxin (BoNT) in the treatment of movement disorders. METHODS: A literature search was performed including MEDLINE and Current Contents for therapeutic articles relevant to BoNT and selected movement disorders. Authors reviewed, abstracted, and classified articles based on American Academy of Neurology criteria (Class I-IV). RESULTS: The highest quality literature available for the respective indications was as follows: blepharospasm (two Class II studies); hemifacial spasm (one Class II and one Class III study); cervical dystonia (seven Class I studies); focal upper extremity dystonia (one Class I and three Class II studies); focal lower extremity dystonia (one Class II study); laryngeal dystonia (one Class I study); motor tics (one Class II study); and upper extremity essential tremor (two Class II studies). RECOMMENDATIONS: Botulinum neurotoxin should be offered as a treatment option for the treatment of cervical dystonia (Level A), may be offered for blepharospasm, focal upper extremity dystonia, adductor laryngeal dystonia, and upper extremity essential tremor (Level B), and may be considered for hemifacial spasm, focal lower limb dystonia, and motor tics (Level C). While clinicians' practice may suggest stronger recommendations in some of these indications, evidence-based conclusions are limited by the availability of data.

Reporting clinical trials: full access to all the data.

Authors' right to access to all data obtained in their study

International Cooperative Ataxia Rating Scale for pharmacological assessment of the cerebellar syndrome. The Ataxia Neuropharmacology Committee of the World Federation of Neurology.

Despite the involvement of cerebellar ataxia in a large variety of conditions and its frequent association with other neurological symptoms, the quantification of the specific core of the cerebellar syndrome is possible and useful in Neurology. Recent studies have shown that cerebellar ataxia might be sensitive to various types of pharmacological agents, but the scales used for assessment were all different. With the long-term goal of double-blind controlled trials-multicentric and international-an ad hoc Committee of the World Federation of Neurology has worked to propose a one-hundred-point semi-quantitative International Cooperative Ataxia Rating Scale (ICARS). The scale proposed involves a compartimentalized quantification of postural and stance disorders, limb ataxia, dysarthria and oculomotor disorders, in order that a subscore concerning these symptoms may be separately studied. The weight of each symptomatologic compartment has been carefully designed. The members of the Committee agreed upon precise definitions of the tests, to minimize interobserver variations. The validation of this scale is in progress.

Biomechanical assessment of quiet standing and changes associated with aging.

The kinematics of standing balance were analyzed in 24 normal subjects, aged 21 to 78 years, to examine differences attributable to age, visual input, and sex. Movements of individual body segments, displacement of the center of gravity (COG), and position of the center of pressure (COP) were measured, and total path length and variability about the mean position were derived from the resulting values. Aging was associated with an increase in variability of the COG, head, and hip, but not in path length. The changes, which may be clinically interpreted as excess postural sway, do not show stability deficits as a consequence of aging. On the contrary, older subjects seem to adopt a postural control strategy that achieves comparable stability during quiet standing. Eye closure increased the anterior-posterior COP path length without corresponding changes in the COG, indicating an increase in small accelerations without associated instability. There was more medial-lateral movement in women than in men. Quantitative electromyographic measures showed that, in general, quiet standing requires very little muscular activity. We conclude that the task of quiet standing produces no evidence of postural instability concurrent with aging. The altered postural control strategy may be less effective when balance is suddenly or severely compromised.

Biomechanical assessment of upright stance in parkinson's disease: a single-subject study.

In order to evaluate the usefulness of biomechanical measures in the clinical assessment of Parkinson's disease, we studied the kinematics of upright stance in a patient with evident fluctuations in clinical state (ON-OFF), which allowed us to optimize experimental control. We determined the total amount of movement and the variability of whole body and body segment kinematics in the vertical, anterior-posterior (A-P), and medial-lateral planes. The total excursion parameter (TEX) represented the co-ordinate path over a 20 s period, and the movement variability parameter (VAR) was calculated based on the standard deviation about the quadratic fit to this path. Discriminant analysis was employed to assess the ability of these parameters to discriminate the patient's clinical state, and statistical reduction of the number of measures was accomplished with a stepwise selection procedure. Measures of shoulder A-P movement and the vertical motion of the centre of gravity (COG) were selected for inclusion in both discriminant functions. The VAR function included only four measures (vertical COG and A-P head, shoulder, and hip), while the TEX function required six measures to discriminate the clinical state. Results obtained with the VAR function were superior to those obtained with TEX, and VAR discriminated the OFF state, a common characteristic of Parkinson's disease, especially well. The results are promising, as the measures appear sensitive to the patient's clinical state even though fluctuation of symptoms was reduced in the latter part of the study by various treatments.