The rise of Parkinson's disease is a global challenge, but efforts to tackle this must begin at a national level: a protocol for national digital screening and "eat, move, sleep" lifestyle interventions to prevent or slow the rise of non-communicable diseases in Thailand.

The rising prevalence of Parkinson's disease (PD) globally presents a significant public health challenge for national healthcare systems, particularly in low-to-middle income countries, such as Thailand, which may have insufficient resources to meet these escalating healthcare needs. There are also many undiagnosed cases of early-stage PD, a period when therapeutic interventions would have the most value and least cost. The traditional "passive" approach, whereby clinicians wait for patients with symptomatic PD to seek treatment, is inadequate. Proactive, early identification of PD will allow timely therapeutic interventions, and digital health technologies can be scaled up in the identification and early diagnosis of cases. The Parkinson's disease risk survey (TCTR20231025005) aims to evaluate a digital population screening platform to identify undiagnosed PD cases in the Thai population. Recognizing the long prodromal phase of PD, the target demographic for screening is people aged ≥ 40 years, approximately 20 years before the usual emergence of motor symptoms. Thailand has a highly rated healthcare system with an established universal healthcare program for citizens, making it ideal for deploying a national screening program using digital technology. Designed by a multidisciplinary group of PD experts, the digital platform comprises a 20-item questionnaire about PD symptoms along with objective tests of eight digital markers: voice vowel, voice sentences, resting and postural tremor, alternate finger tapping, a "pinch-to-size" test, gait and balance, with performance recorded using a mobile application and smartphone's sensors. Machine learning tools use the collected data to identify subjects at risk of developing, or with early signs of, PD. This article describes the selection and validation of questionnaire items and digital markers, with results showing the chosen parameters and data analysis methods to be robust, reliable, and reproducible. This digital platform could serve as a model for similar screening strategies for other non-communicable diseases in Thailand.

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.

Self-treatment of freezing of gait in Parkinson's disease patients using silicone pads to apply Thai acupressure to plantar acupoints: A randomised, controlled trial.

Introduction: Freezing of gait (FOG) involves dysfunction of the motor and sensory systems. Peripheral sensory stimuli, including Thai acupressure, can improve proprioceptive function and decrease FOG episodes. Here, we sought to determine the efficacy of acupressure as a self-treatment to alleviate FOG in patients with Parkinson's disease (PD). Methods: We conducted an open-label, controlled trial of 60 PD patients with FOG while medicated, randomised into two groups: an active-treatment group using silicone pads to apply pressure to plantar acupoints on the head of the big toe and the base of the first metatarsal bone on each foot for 6 s using patient body weight while seated, repeated four times for each acupoint bilaterally, and a sham-treatment group using a similar protocol without the silicone pads. The primary outcome was stride length. Secondary outcomes included FOG episodes, FOG duration, percent duration of FOG to total gait time (%FOG), and gait parameters. A baseline-adjusted analysis of covariance was used to compare outcomes between the two groups. Results: Compared with the sham treatment, the active treatment increased stride length, gait velocity, and cadence (all p < 0.001), and decreased FOG episodes and duration (both p < 0.001), %FOG (p = 0.011), and double-support time (p < 0.001). No adverse effects were noted. Conclusions: Acupressure using silicone pads to stimulate plantar acupoints for self-treatment is a noninvasive, simple, safe way to improve gait and alleviate FOG in patients with PD. Clinical Trial Registration: We registered the study prospectively in the Thai Clinical Trial Registry No. TCTR20200317001.

Exploring the Complex Phenotypes of Impaired Finger Dexterity in Mild-to-moderate Stage Parkinson's Disease: A Time-Series Analysis.

BACKGROUND: Impaired dexterity is an early motor symptom in Parkinson's disease (PD) that significantly impacts the daily activity of patients; however, what constitutes complex dexterous movements remains controversial. OBJECTIVE: To explore the characteristics of finger dexterity in mild-to-moderate stage PD. METHODS: We quantitatively assessed finger dexterity in 48 mild-to-moderate stage PD patients and 49 age-matched controls using a simple alternating two-finger typing test for 15 seconds. Time-series analyses of various kinematic parameters with machine learning were compared between sides and groups. RESULTS: Both the more and less affected hands of patients with PD had significantly lower typing frequency and slower typing velocity than the non-dominant and the dominant hands of controls (p = 0.019, p = 0.016, p < 0.001, p < 0.001). The slope of the typing velocity decreased with time, indicating a sequence effect in the PD group. A typing duration of 6 seconds was determined sufficient to discriminate PD patients from controls. Typing error, repetition, and repetition rate were significantly higher in the more affected hands of patients with PD than in the non-dominant hand of controls (p < 0.001, p = 0.03, p < 0.001). The error rate was constant, whereas the repetition rate was steep during the initiation of typing. A predictive model of the more affected hand demonstrated an accuracy of 70% in differentiating PD patients from controls. CONCLUSION: Our study demonstrated complex components of impaired finger dexterity in mild-to-moderate stage PD, namely bradykinesia with sequence effects, error, and repetition at the initiation of movement, suggesting that multiple neural networks may be involved in dexterity deficits in PD.

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.

Role of supplementary motor area in cervical dystonia and sensory tricks.

Sensory trick is a characteristic feature of cervical dystonia (CD), where a light touch on the area adjacent to the dystonia temporarily improves symptoms. Clinical benefit from sensory tricks can be observed before tactile contact is made or even by imagination. The supplementary motor area (SMA) may dynamically interact with the sensorimotor network and other brain regions during sensory tricks in patients with CD. In this study, we examined the functional connectivity of the SMA at rest and during sensory trick performance and imagination in CD patients compared to healthy controls using functional magnetic resonance imaging. The functional connectivity between the SMA and left intraparietal sulcus (IPS) region was lower in CD patients at rest and it increased with sensory trick imagination and performance. SMA-right cerebellum connectivity also increased with sensory trick imagination in CD patients, while it decreased in healthy controls. In CD patients, SMA connectivity increased in the brain regions involved in sensorimotor integration during sensory trick performance and imagination. Our study results showed a crucial role of SMA in sensorimotor processing during sensory trick performance and imagination and suggest the IPS as a novel potential therapeutic target for brain modulation.

Multimodal imaging of essential tremor and dystonic tremor.

Despite recent advances in tremor and dystonia classification, it remains difficult to discriminate essential tremor from dystonic tremor as they are similar in appearance and no biomarker exists. Further, tremor can appear in the same or a different body part than the dystonia. The aim of the current study was to better understand the differential pathophysiology of these tremors. We designed a cross-sectional case-control study and recruited 16 patients with essential tremor, 16 patients with dystonic tremor, and 17 age-matched healthy volunteers. We used multi-modal imaging combining resting-state functional MRI, diffusion tensor imaging, and magnetic resonance spectroscopy. We measured functional connectivity of resting-state fMRI to assess connectivity in the tremor network, fractional anisotropy and mean diffusivity with diffusion tensor imaging, and GABA+, Glutamate/Glutamine, Choline, and N-Acetylaspartate with spectroscopy (adjusted to Creatine). Our results showed reduced functional connectivity of resting-state fMRI between the cerebellum and dentate nucleus bilaterally for the essential tremor group, but not the dystonic tremor group, compared to healthy volunteers. There was higher fractional anisotropy in the middle cerebellar peduncle bilaterally for the dystonic tremor group compared to the essential tremor group as well as for essential tremor group compared to healthy volunteers. There was also higher fractional anisotropy in the red nucleus and corticospinal tract for essential tremor and dystonic tremor groups compared to healthy volunteers. We also showed reduced mean diffusivity in the cerebellum of both essential tremor and dystonic tremor groups compared to healthy volunteers. Finally, we found elevated GABA+/Cr in the cerebellum of the essential tremor and dystonic tremor groups compared to healthy volunteers, but no difference emerged between essential tremor and dystonic tremor groups. We did not find group differences in the other metabolites. Our results indicate cerebellar alterations in essential tremor and dystonic tremor patients compared to healthy volunteers, and further changes in the cerebellum network for the dystonic tremor patients. suggesting that the cerebellum is affected differently in both tremors.

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.

Clinical features, pathophysiology, treatment, and controversies of tremor in dystonia.

Dystonia and tremor frequently co-occur. In some cases, they have shared biological mechanisms, while in others dystonia and tremor are two comorbid conditions. The term "dystonic tremor" is used to describe tremor in those who have dystonia. Two mutually exclusive definitions of "dystonic tremor" were proposed. According to one definition, dystonic tremor is the tremor in the dystonic body part. An alternate definition of dystonic tremor entails irregular and jerky oscillations that have saw tooth appearance with or without overt dystonia. This paper outlines the differences in two definitions of dystonic tremor and identifies their limitations. Given the diverse views defining "dystonic tremor", this paper will use the term "tremor in dystonia". In addition, we will outline different ways to separate the subtypes of tremor in dystonia. Then we will discuss pathophysiological mechanisms derived from the objective measures and single neuron physiology analyses of tremor in dystonia. This article is part of the Special Issue "Tremor" edited by Daniel D. Truong, Mark Hallett, and Aasef Shaikh.

Validation of the Thai Version of the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale.

OBJECTIVE: This study aims to validate the Thai translation of the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS). METHODS: The English version was translated into Thai and then back-translated into English. The translated version underwent 2 rounds of cognitive pretesting to assess the ease of comprehension, ease of use and comfort with the scale. Then, it underwent large clinimetric testing. RESULTS: The Thai version was validated in 354 PD patients. The comparative fit index (CFI) for all four parts of the Thai version of the MDS-UPDRS was 0.93 or greater. Exploratory factor analysis identified isolated item differences in factor structure between the Thai and English versions. CONCLUSION: The overall factor structure of the Thai version was consistent with that of the English version based on the high CFIs (all CFI ≥ 0.90). Hence, it can be designated the official Thai version of the MDS-UPDRS.

The clinical and electrophysiological investigation of tremor.

The various forms of tremor are now classified in two axes: clinical characteristics (axis 1) and etiology (axis 2). Electrophysiology is an extension of the clinical exam. Electrophysiologic tests are diagnostic of physiologic tremor, primary orthostatic tremor, and functional tremor, but they are valuable in the clinical characterization of all forms of tremor. Electrophysiology will likely play an increasing role in axis 1 tremor classification because many features of tremor are not reliably assessed by clinical examination alone. In particular, electrophysiology may be needed to distinguish tremor from tremor mimics, assess tremor frequency, assess tremor rhythmicity or regularity, distinguish mechanical-reflex oscillation from central neurogenic oscillation, determine if tremors in different body parts, muscles, or brain regions are strongly correlated, document tremor suppression or entrainment by voluntary movements of contralateral body parts, and document the effects of voluntary movement on rest tremor. In addition, electrophysiologic brain mapping has been crucial in our understanding of tremor pathophysiology. The electrophysiologic methods of tremor analysis are reviewed in the context of physiologic tremor and pathologic tremors, with a focus on clinical characterization and pathophysiology. Electrophysiology is instrumental in elucidating tremor mechanisms, and the pathophysiology of the different forms of tremor is summarized in this review.

Correction: Impact of disease stage and age at Parkinson's onset on patients' primary concerns: Insights for targeted management.

[This corrects the article DOI: 10.1371/journal.pone.0243051.].

Using machine learning-based analytics of daily activities to identify modifiable risk factors for falling in Parkinson's disease.

BACKGROUND: Although risk factors that lead to falling in Parkinson's disease (PD) have been previously studied, the established predictors are mostly non-modifiable. A novel method for fall risk assessment may provide more insight into preventable high-risk activities to reduce future falls. OBJECTIVES: To explore the prediction of falling in PD patients using a machine learning-based approach. METHOD: 305 PD patients, with or without a history of falls within the past month, were recruited. Data including clinical demographics, medications, and balance confidence, scaled by the 16-item Activities-Specific Balance Confidence Scale (ABC-16), were entered into the supervised machine learning models using XGBoost to explore the prediction of fallers/recurrent fallers in two separate models. RESULTS: 99 (32%) patients were fallers and 58 (19%) were recurrent fallers. The accuracy of the model to predict falls was 72% (p = 0.001). The most important factors were item 7 (sweeping the floor), item 5 (reaching on tiptoes), and item 12 (walking in a crowded mall) in the ABC-16 scale, followed by disease stage and duration. When recurrent falls were analysed, the models had higher accuracy (81%, p = 0.02). The strongest predictors of recurrent falls were item 12, 5, and 10 (walking across parking lot), followed by disease stage and current age. CONCLUSION: Our machine learning-based study demonstrated that predictors of falling combined demographics of PD with environmental factors, including high-risk activities that require cognitive attention and changes in vertical and lateral orientations. This enables physicians to focus on modifiable factors and appropriately implement fall prevention strategies for individual patients.

Impact of disease stage and age at Parkinson's onset on patients' primary concerns: Insights for targeted management.

BACKGROUND: The concerns of people with Parkinson's disease (PD) about their disease are often different from the objective clinical picture and subject to various influencing factors, including disease progression. Currently our understanding of these concerns is limited, particularly in Asian countries. METHODS: A 50-item survey on Parkinson's Disease Patients' Concerns (PDPC Survey) was developed by a multidisciplinary care team. The subjective greatest concerns (most commonly concerning symptoms) of patients at a specialist centre in Bangkok, Thailand, were explored and categorised according to disease stage and age at onset of PD. RESULTS: Data for 222 patients showed concerns varied widely. Motor symptoms giving the greatest concern were problems with walking and/or balance (40.5% of patients), while the most commonly concerning non-motor symptom (NMS) was constipation (41.0%). Patterns were observed amongst different patient subgroups. Early PD patients (H&Y stage 1) were more concerned about NMS than motor symptoms, while the reverse was true for advanced PD patients. Young-onset PD patients showed significantly greater concerns than typical-onset patients about motor symptoms relating to social functioning, working and stigmatisation, such as speech (p = 0.003). CONCLUSIONS: This study, in an Asian patient cohort, provides an assessment of a wide range of PD patients' concerns, encompassing not only motor symptoms and NMS, but also treatment-related adverse events, care in the advanced stage, and the need for assistive devices. Identifying the concerns of individual PD patients and implementing a patient-centred approach to care is critical to their wellbeing and optimal outcomes. The PDPC survey can help healthcare teams build a more accurate picture of patients' experiences to inform clinical management.

The Pathophysiology of Dystonic Tremors and Comparison With Essential Tremor.

There are two types of dystonic tremor syndromes (DTS), dystonic tremor (DT) and tremor associated with dystonia (TAWD), and neither is understood. DTS likely share some mechanisms with nontremulous dystonia, and there may also be overlaps with essential tremor (ET). We studied 21 ET (8 females, 13 males) and 22 DTS human patients (10 females, 12 males), including 13 human patients with DT (writer's cramp with writing tremor) and 9 human patients with tremor associated with dystonia (TAWD; cervical dystonia with hand tremor). Tremors were analyzed using accelerometry and surface EMG of the antagonist pairs of arm muscles during posture, simple kinetic movement, and writing. Cerebellar inhibition was performed to assess cerebello-thalamo-cortical involvement. DT exhibited higher variability of peak frequency and greater instability of tremor burst intervals over time (higher tremor stability index) than ET or TAWD regardless of tasks. Intermuscular coherence magnitude between the antagonist pairs increased during the writing task in DT, but not ET or TAWD. ET and TAWD exhibited different phase relationships of the temporal fluctuations of voluntary movement and tremor in the kinetic condition. A linear discriminant classifier based on these tremor parameters was able to distinguish the three groups with a classification accuracy of 95.1%. Cerebellar inhibition was significantly reduced in DT, but not in TAWD, compared with ET and healthy controls. Our study shows that the two DTS are distinct entities with DT closer to nontremorous dystonia and TAWD closer to ET.SIGNIFICANCE STATEMENT This study provides novel findings about characteristics and pathophysiology of the two different types of dystonic tremor syndromes compared with essential tremor. Patients with DTS are classified into DT who have dystonia and tremor in the same area, and tremor associated with dystonia (TAWD) who have dystonia and tremor elsewhere. Our results showed that DT exhibits increased tremor variability, instability, and intermuscular coherence, and decreased cerebello-thalamo-cortical inhibition compared with TAWD. Our study shows that DT and TAWD are distinct phenotypes, and that the physiological characteristics of DT are more similar to nontremorous dystonia, and TAWD is closer to ET.

If Your Patients Were Too Embarrassed to Go Out in Public, What Would You Do? - Public Education to Break the Stigma on Parkinson's Disease Using Integrated Media.

PURPOSE: People with Parkinson's (PwP) often feel stigmatized, especially when their symptoms are visually prominent. In some countries, public awareness of Parkinson's disease can be minimal, leading to social challenges for PwP. PATIENTS AND METHODS: A public educational campaign using videos (VDO) showing 5 PwP in different social situations that their symptoms could be a source of inconvenience to others were launched on Facebook (FB) and television (TV). We describe the process and report the impact of the campaign on patients and the public. Number of shares and likes and the first 100 comments on FB were analyzed. RESULTS: There were almost 1 million views, 680,000 likes, and 256,000 shares in the Center's and popular Facebook Pages within 24 hours, subsequently reaching 4.4 million views, 138,000 likes, and 78,000 shares. Patients reported changed behavior and demeanor by the public towards them. The public's comments ranged from stating that they have seen PwP without knowing what it was to requests for more information about PD to thanks for the informative VDO. People also shared their experiences with PwP. CONCLUSION: The campaign was impactful in creating awareness about PD. Creating appealing content with appropriate video length and collaborating with community groups that have relevant skills can help in creating and disseminating an educational video which creates a significant impact on society as a whole. This can be emulated to educate the public about other diseases.

Orofacial dystonia and asssociated bulbar symptoms in multiple system atrophy: A blinded video analysis.

BACKGROUND: Orofacial dystonia (OFD) is considered a supporting feature for a diagnosis of Multiple System Atrophy (MSA). However, the association of OFD with other adjacent symptoms has not been explored. OBJECTIVES: To identify clinical characteristics of OFD and associated bulbar symptoms in MSA patients. METHODS: In this blinded trial, video clips of 24 MSA patients were reviewed by two movement disorder neurologists who rated the presence of OFD. Analysis was performed to determine correlations between the presence of OFD and clinical demographics as well as associated bulbar symptoms. RESULTS: There were 14 patients with MSA-P and 10 patients with MSA-C. OFD was identified in seven patients (29.16%) and MSA-P as the majority (85.71%). Oromandibular dystonia (OMD) was hardly ever identified in isolation with the most frequent combination being OMD with upper facial dystonia, blepharospasm and platysma dystonia. All OMD patients had the jaw-closing subtype. Mean onset of OFD was 1.7 (SD = 0.5) years after the first symptom onset and 1.1 years (SD = 0.4) after the introduction of levodopa. Patients with OFD used significantly higher levodopa equivalent daily dosage (LEDD) than those without (p = 0.02). There were moderate correlations between the presence of OFD and LEDD (r = 0.458, p = 0.02), and dysarthria (r = 0.639, p = 0.001) while a strong correlation was demonstrated between the presence of OFD and dysphagia (r = 0.9, p < 0.001). CONCLUSION: OFD is probably a manifestation of motor fluctuations in MSA and its presence is significantly associated with bulbar symptoms. Neurologists should inquire about dysphagia when encountering MSA patients with OFD for early recognition and appropriate management.

Establishing apomorphine treatment in Thailand: understanding the challenges and opportunities of Parkinson's disease management in developing countries.

INTRODUCTION: The increasing global burden of Parkinson's disease (PD) poses a particular challenge for developing countries, such as Thailand, when delivering care to a geographically diverse populace with limited resources, often compounded by a lack of expertise in the use of certain PD medications, such as device-aided therapies (DAT). AREAS COVERED: A panel of local, regional, and international PD experts convened to review the unmet needs of PD in Thailand and share insights into effective delivery of DAT, focusing on experience with apomorphine infusion. Despite its proven efficacy and safety, implementation of apomorphine infusion as a new option was not straightforward. This has prompted a range of health-care professional and patient-focused initiatives, led by the Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders in Bangkok, to help establish a more coordinated approach to PD management throughout the country and ensure patients have access to suitable treatments. EXPERT OPINION: Overcoming the challenges of education, proficiency, resource capacity and standard of care for PD patients in developing countries requires a coordinated effort both nationally and beyond. The best practices identified in Thailand following the introduction of apomorphine infusion might be helpful for other countries when implementing similar programs.

Delivering patient-centered care in Parkinson's disease: Challenges and consensus from an international panel.

An international panel of movement disorders specialists explored the views and perceptions of people with Parkinson's disease (PD) about their condition and its treatment, including the potential mismatch between the clinician's view of the patient's condition and their own view of what aspects of the disease most affect their daily lives. The initiative was focused on Asian countries, so participants comprised experts in the management of PD from key centers in Asia, with additional insight provided by European and the North American movement disorders experts. Analysis of peer-reviewed publications on patient perceptions of PD and the factors that they consider important to their wellbeing identified several contributing factors to the mismatch of views, including gaps in knowledge of PD and its treatment, an understanding of the clinical heterogeneity of PD, and the importance of a multidisciplinary approach to patient care. The faculty proposed options to bridge these gaps to ensure that PD patients receive the personalized treatment they need to achieve the best possible outcomes. It was considered essential to improve patient knowledge about PD and its treatment, as well as increasing the awareness of clinicians of PD heterogeneity in presentation and treatment response. A multidisciplinary and shared-care approach to PD was needed alongside the use of patient-centered outcome measures in clinical trials and clinical practice to better capture the patient experience and improve the delivery of individualized therapy.