Treatment of end-of-dose wearing-off in parkinson's disease: stalevo (levodopa/carbidopa/entacapone) and levodopa/DDCI given in combination with Comtess/Comtan (entacapone) provide equivalent improvements in symptom control superior to that of traditional levodopa/DDCI treatment.

The aim of this study was to evaluate the efficacy of the new optimised levodopa, Stalevo (levodopa, carbidopa and entacapone) in patients with Parkinson's disease experiencing end-of-dose wearing-off. Treatment with Stalevo was compared to treatment with traditional immediate-release levodopa and dopa-decarboxylase inhibitor (DDCI) formulations along with adjunct entacapone (Comtess/Comtan). A European, open, parallel-group, active treatment-controlled phase IIIb study evaluating 176 patients randomised to switch from their current regimen of levodopa/DDCI to either an equivalent dose of Stalevo or levodopa/DDCI plus entacapone. After 6 weeks, treatments were assessed using the Clinical Global Impression of Change, the Unified Parkinson's Disease Rating Scale and a Motor Fluctuations Questionnaire. Over 70% of patients in both the Stalevo and adjunct entacapone arms felt that they were clinically improved and over 80% experienced a reduction in fluctuations. Although there was no significant difference between Stalevo and levodopa/DDCI plus entacapone with regard to motor improvement and side effects, 81% of patients stated that they preferred treatment with Stalevo compared with taking two separate tablets (i.e. levodopa/DDCI and entacapone). Stalevo was well tolerated and safe when substituted for levodopa DDCI preparations.

Dual channel deep brain stimulation system (Kinetra) for Parkinson's disease and essential tremor: a prospective multicentre open label clinical study.

OBJECTIVES: To evaluate the safety and efficacy of a new dual channel stimulator (Kinetra) in patients with severe Parkinson's disease (PD) or essential tremor (ET). METHODS: 111 patients with PD and 18 with ET were studied. Leads were implanted into the subthalamic nucleus (STN) or internal globus pallidus of patients with the akinetic/rigid type of PD. Leads were implanted into the ventral intermediate nucleus (VIM) of the thalamus or the STN in patients with the tremor dominant type of PD and in those with ET. Technical data on the device and adverse events occurring during the study were documented. Patients were assessed with established and validated clinical scales before surgery and at three and six months' follow up. RESULTS: No device failure or unexpected adverse events occurred during the study. The dual channel stimulator used in stimulation of the STN, internal globus pallidus, and VIM in PD and ET was as safe and effective as the single channel stimulators in use. Mortality, morbidity, and infections were documented in the 129 treated patients. The parameter settings were similar to those usually programmed with single channel stimulators. Time spent in the operating room to implant the Kinetra system was systematically documented. In the PD group, improvement in the unified Parkinson's disease rating scale motor score, decrease in medication OFF periods, and reduced levodopa induced dyskinesia by bilateral STN stimulation were similar to those previously reported with bilaterally applied single channel stimulators. In the ET group upper and lower limb tremor scores were reduced by VIM stimulation. Activities of daily living improved in both disease groups. CONCLUSION: The Kinetra facilitated bilateral deep brain stimulation implantation surgery and is easy to use. It offers more advantages for the patient than the single channel stimulators; consequently, this new device may be recommended to treat patients with severe PD and ET.

[Surgical treatment of Parkinson disease and essential tremor]. / Kirurgisk behandling af Parkinsons sygdom og essentiel tremor.

Recognition of the often failing effect of levodopa treatment as Parkinson's disease (PD) progresses has led to the resumption of surgical treatment. In the 1950'ies and 1960'ies pallidotomy and thalamotomy were commonly performed to reduce parkinsonian symptoms, whilst today these permanent lesions are replaced by Deep Brain Stimulation (DBS) of implanted leads. The advantages of DBS in either the subthalamic nuclei (STN) or the internal part of the globus pallidus are that implantation of leads into these nuclei can be performed bilaterally, and that DBS is a reversible treatment. Pallidotomy and thalamotomy are permanent lesions and if performed bilaterally these lesions often cause unacceptable complications. Bilateral stimulation of the STN is often preferred due to the reduction of rigidity, hypokinesia and tremor as well as the significant reduction of dyskinesias and off-periods. The motor functions are significantly improved and stabilized.

[Treatment of severe Parkinson disease with electric stimulation of the subthalamic nuclei]. / Behandling af svaer Parkinsons sygdom med elektrisk stimulation i nucleus subthalamicus.

INTRODUCTION: Patients with Parkinson's disease suffering from severe fluctuations, i.e. dyskinesias and on-off periods and/or severe tremor, who cannot be improved by adjustment of the medical treatment, can be treated with deep brain stimulation via leads implanted bilaterally into the subthalamic nuclei. METHODS: Nine patients with advanced idiopathic Parkinson's disease were treated with stereotactic and bilateral implantation of leads into the subthalamic nuclei. All patients had levodopa responsive Parkinson's disease and levodopa induced fluctuations in the form of on-off periods and dyskinesias. The mean age was 61 years and the mean duration of disease 15 years. The patients were followed for 12 months and evaluated with the Unified Parkinson's Disease Rating Scale off and on medications before and after lead implantation. RESULTS: The Hoehn & Yahr stage fell from 3.9/2.8 before lead implantation and off/on medication to 3.0/2.3 with lead stimulation turned on and off/on medication. The activity of daily living (ADL) index was significantly improved and reduced from 27/13 before lead implantation and off/on medication to 12/7 with the stimulation turned on and off/on medication i.e. with 55%/46% on stimulation. The motor score was likewise significantly improved and reduced from 55/28 to 24/17 i.e. with 56%/39% on stimulation. The most important results of deep brain stimulation in the subthalamic nuclei is the significant reduction of the motor fluctuations. On stimulation off periods were reduced from 30% to 6% and the dyskinesias were significantly reduced from 47% to 14% of the daytime. The mean dose of levodopa equivalent medication was reduced with 26%. DISCUSSION: In conclusion, patients with advanced Parkinson's disease and levodopa induced fluctuations can be successfully treated with bilateral high frequency electric stimulation of leads implanted into the subthalamic nuclei.

A comparison of physical characteristics between patients seeking treatment for neck pain and age-matched healthy people.

OBJECTIVE: To compare physical characteristics of the cervical musculature, including maximal isometric strength of the flexors and extensors, relative isometric endurance of the extensors and the active range of motion (ROM) in extension in a group of patients seeking treatment for chronic neck pain and a group of age-matched healthy people. SETTING: Department of Medical Orthopedics, National University Hospital, Denmark. METHODS: One hundred and nineteen chronic neck-pain patients underwent physical testing for active ROM in extension, maximal isometric torque in extension and flexion and relative isometric endurance in extension before entering a clinical controlled trial studying the treatment of chronic neck pain. Their results were then compared with those of 80 age-matched healthy people. RESULTS: The reliability study demonstrated good within-day and day-to-day reproducibility for active ROM. Active ROM was significantly reduced in female patients, but not in all male age groups. Patients exhibited clinically and statistically significant reductions in maximal isometric torque in both the flexors and extensors of the cervical spine, with the greatest reduction seen in the extensor muscle group. Most patient groups demonstrated a significant reduction in relative isometric endurance of the extensors. CONCLUSIONS: In agreement with most low-back comparisons between patients and age-matched healthy people, the greatest relative muscular deficiencies seem to be in the extensor muscle group. Additionally, most patients exhibit a significant decrease in active ROM during extension. The clinical utility of physical measurements has not been firmly established.

Rehabilitation of neck/shoulder patients in primary health care clinics.

OBJECTIVE: To review the literature pertaining to neck/shoulder pain and its treatment primarily through rehabilitation. A discussion regarding the theoretical basis for clinical rehabilitation is presented. DATA SOURCE: A Medline literature search was performed. English and Scandinavian language articles were reviewed. Key words included neck/shoulder pain, neck pain, rehabilitation and exercise. STUDY SELECTION: The studies included used rehabilitation of the cervical musculature as the main treatment therapy on patients suffering from neck/shoulder pain as defined by the Standardized Nordic Questionnaires. DATA SYNTHESIS: The relatively new concept of neck/shoulder rehabilitation seems to result in pain reduction, restoration of functional values and psychological benefit for patients suffering from chronic, recurrent, post-traumatic or postoperative neck/shoulder pain. Successful protocols seem to be dependent upon sufficient dosage, duration and a relative disregard of pain. Side effects seem to be rare. CONCLUSIONS: Rehabilitation of patients with neck/shoulder pain offers great promise; sufficient documentation exists to warrant serious consideration from all practitioners in the primary health sector. Future studies will be necessary to further clarify which rehabilitative procedures are most suitable for different patient types.

Implementation of neck/shoulder rehabilitation in primary health care clinics.

OBJECTIVE: To provide primary health care practitioners with the practical information necessary to implement rehabilitation of patients with neck/shoulder pain in clinical facilities. Equipment and program design are discussed in detail. DATA SOURCE: A Medline literature search was performed. English and Scandinavian language references were included in the review. Key words included neck/shoulder pain, neck pain, rehabilitation, equipment, exercise. STUDY SELECTION: The studies selected included clinical trials in which rehabilitation was the main intervention in the treatment of patients with neck/shoulder pain. DATA SYNTHESIS: Reestablishing functional capacities of the musculature of the cervical spine can be accomplished with modest equipment and can be easily incorporated into the clinical setting. The extensors of the cervical spine are the most important muscle group that require rehabilitation and exhibit the highest values in all strength parameters. High-intensity rehabilitative protocols accompanied by the encouragement of fellow patients and support from personnel are essential for treatment success. CONCLUSIONS: Complete primary health care treatment of patients with chronic, recurrent and post-traumatic neck/shoulder pain will necessitate longer rehabilitation programs. Future studies will provide additional information regarding specific program design.

Serum cobalamin and methylmalonic acid in Alzheimer dementia.

The cobalamin status was evaluated in Alzheimer dementia (n = 26), other dementias (n = 24), various gerontopsychiatric disorders (n = 25), and in neuro-psychiatrically healthy controls (n = 20). Supplementing serum cobalamin we measured methylmalonic acid (MMA), a metabolite accumulating early in cobalamin deficiency. Subnormal cobalamin and/or clearly elevated MMA concentrations were found in 11 cases: 7 Alzheimer patients (27%), 2 with other dementias (8%), one psychiatric patient (4%), and one control (5%). None presented the typical neurologic features of cobalamin deficiency and macrocytosis was found in only one. The mean cobalamin concentration was significantly lower in Alzheimer patients (179 +/- 18 pmol/l) than in the age-matched controls (256 +/- 23 pmol/l) (p = 0.013) and the other patient groups. Correspondingly, the mean MMA level was higher in the Alzheimer group (0.480 +/- 0.062 mumol/l) than in any other diagnostic group (controls: 0.347 +/- 0.040 mumol/l). Comparing the Alzheimer group to the other groups as a whole, the elevation was significant (p = 0.0097). Our findings indicate that Alzheimer patients are particularly prone to cobalamin deficiency, and even subtle biochemical signs of deficiency seem to justify treatment.