Movement disorders in Indochina: Resource challenges and future solutions.

Movement disorders are a major cause of disability worldwide and their increasing prevalence predicts a substantial future burden of care. Impactful patient care requires availability of, and accessibility to, effective medications, knowledge, and disease awareness among both medical professionals and patients, driven by skilled personnel to harness and manage resources. The highest burden of movement disorders is in low-to-middle income countries where resources are often limited and infrastructure is insufficient to meet growing demands. This article focuses on the specific challenges faced in the management and delivery of care for movement disorders in Indochina, the mainland region of Southeast Asia comprising the neighboring countries of Cambodia, Laos, Malaysia, Myanmar, Thailand, and Vietnam. The first Indochina Movement Disorders Conference was held in August 2022 in Ho Chi Minh City, Vietnam, to provide a platform to better understand the situation in the region. Future management of movement disorders in Indochina will require progressive adaptation of existing practices to reflect modern approaches to care delivery. Digital technologies offer an opportunity to strengthen these processes and address the challenges identified in the region. Ultimately, a long-term collaborative approach by regional healthcare providers is key.

COVID19-associated new-onset movement disorders: a follow-up study.

BACKGROUND: Neurological symptoms are common manifestation in acute COVID-19. This includes hyper- and hypokinetic movement disorders. Data on their outcome, however, is limited. METHODS: Cases with new-onset COVID-19-associated movement disorders were identified by searching the literature. Authors were contacted for outcome data which were reviewed and analyzed. RESULTS: Movement disorders began 12.6 days on average after the initial onset of COVID-19. 92% of patients required hospital admission (mean duration 23 days). In a fraction of patients (6 of 27; 22%; 4 males/2 females, mean age 66.8 years) the movement disorder (ataxia, myoclonus, tremor, parkinsonism) was still present after a follow-up period of 7.5 ± 3 weeks. Severe COVID-19 in general and development of encephalopathy were risk factors, albeit not strong predictors, for the persistence. CONCLUSIONS: The prognosis of new-onset COVID-19-associated movement disorder appears to be generally good. The majority recovered without residual symptoms within several weeks or months. Permanent cases may be due to unmasking of a previous subclinical movement disorder or due to vascular/demyelinating damage. Given the relatively low response rate of one third only and the heterogeneity of mechanisms firm conclusions on the (long-term) outome cannot, however, be drawn.

Technological evaluation of strategies to get out of bed by people with Parkinson's disease: Insights from multisite wearable sensors.

Background: Difficulty getting out of bed is a common night-time and early morning manifestation of Parkinson's disease (PD), rated by 40% of the patients as their most concerning motor symptoms. However, current assessment methods are based on clinical interviews, video analysis, and clinical scales as objective outcome measures are not yet available. Objective: To study the technical feasibility of multisite wearable sensors in the assessment of the supine-to-stand (STS) task as a determinant of the ability to get out of bed in patients with PD and age-matched control subjects, and develop relevant objective outcome measures. Methods: The STS task was assessed in 32 patients with PD (mean Hoehn and Yahr; HY = 2.5) in the early morning before their first dopaminergic medication, and in 14 control subjects, using multisite wearable sensors (NIGHT-Recorder®; trunk, both wrists, and both ankles) in a sleep laboratory. Objective getting out of bed parameters included duration, onset, velocity and acceleration of truncal rotation, and angle deviation (a°) from the z-axis when subjects rose from the bed at different angles from the x-axis (10°, 15°, 30°, 45°, and 60°) as measures of truncal lateral flexion. Movement patterns were identified from the first body part or parts that moved. Correlation analysis was performed between these objective outcomes and standard clinical rating scales. Results: Compared to control subjects, the duration of STS was significantly longer in patients with PD (p = 0.012), which is associated with a significantly slower velocity of truncal rotation (p = 0.003). Moderate and significant correlations were observed between the mean STS duration and age, and the Nocturnal Hypokinesia Questionnaire. The velocity of truncal rotation negatively and significantly correlated with HY staging. Any arm and leg moved together as the first movement significantly correlated with UPDRS-Axial and item #28. Several other correlations were also observed. Conclusion: Our study was able to demonstrate the technical feasibility of using multisite wearable sensors to quantitatively assess early objective outcome measures of the ability of patients with PD to get out of bed, which significantly correlated with axial severity scores, suggesting that axial impairment could be a contributing factor in difficulty getting out of bed. Future studies are needed to refine these outcome measures for use in therapeutic trials related to nocturia or early morning akinesia in PD.

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.

Movement Disorders Induced by SARS-CoV-2 Infection: Protocol for a Scoping Review.

Infections are a significant cause of movement disorders. The clinical manifestations of SARS-CoV-2 infection are variable, with up to one-third of patients developing neurologic complications, including movement disorders. This scoping review will lay out a comprehensive understanding of movement disorders induced by SARS-CoV-2 infection. We aim to investigate the epidemiology, clinical and paraclinical features, interventions, and diagnostic challenges in patients with different types of movement disorders in the context of SARS-CoV-2 infection. We will search three databases applying appropriate search terms. Inclusion and exclusion criteria are pre-defined; the data of eligible studies will be extracted in standardized forms. We will report the results following Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We will present information for clinicians and other healthcare professionals, policymakers, and public health researchers. In addition, the results of the present review may assist in the development and confirmation of inclusion criteria and research questions for further systematic review or meta-analysis, with more precise, narrower questions.

Digital health technology for non-motor symptoms in people with Parkinson's disease: Futile or future?

INTRODUCTION: There is an ongoing digital revolution in the field of Parkinson's disease (PD) for the objective measurement of motor aspects, to be used in clinical trials and possibly support therapeutic choices. The focus of remote technologies is now also slowly shifting towards the broad but more "hidden" spectrum of non-motor symptoms (NMS). METHODS: A narrative review of digital health technologies for measuring NMS in people with PD was conducted. These digital technologies were defined as assessment tools for NMS offered remotely in the form of a wearable, downloadable as a mobile app, or any other objective measurement of NMS in PD that did not require a hospital visit and could be performed remotely. Searches were performed using peer-reviewed literature indexed databases (MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane CENTRAL Register of Controlled Trials), as well as Google and Google Scholar. RESULTS: Eighteen studies deploying digital health technology in PD were identified, for example for the measurement of sleep disorders, cognitive dysfunction and orthostatic hypotension. In addition, we describe promising developments in other conditions that could be translated for use in PD. CONCLUSION: Unlike motor symptoms, non-motor features of PD are difficult to measure directly using remote digital technologies. Nonetheless, it is currently possible to reliably measure several NMS and further digital technology developments are underway to offer further capture of often under-reported and under-recognised NMS.

Rapid eye movement sleep behavior disorder and rapid eye movement sleep without atonia are more frequent in advanced versus early Parkinson's disease.

STUDY OBJECTIVES: To evaluate macro sleep architecture and characterize rapid eye movement (REM) sleep without atonia (RWA) by using the SINBAR excessive electromyographic (EMG) montage including mentalis and upper extremity muscles in early and advanced Parkinson's disease (PD). METHODS: We recruited 30 patients with early- and advanced-stage of PD according to Movement Disorder Society (MDS) Clinical Diagnostic Criteria. Participants were classified as early-stage PD if they were treatment-naïve or had no motor complications and had been diagnosed with PD within the previous 6 years. Advanced PD was defined as a disease duration equal to or >6 years with or without motor complications. RESULTS: There was significantly shorter REM sleep latency in early as compared to the advanced stage of PD. We found that the sleep Innsbruck Barcelona (SINBAR) EMG index and tonic EMG activity of the mentalis muscle in advanced-stage PD were significantly higher than in early-stage PD with a trend in phasic EMG activity of the flexor digitorum superficialis muscles. The SINBAR EMG index, tonic and any EMG activity of the mentalis muscle, and phasic EMG activity of flexor digitorum superficialis muscles significantly correlated with disease duration. CONCLUSIONS: This study analyzed RWA using the SINBAR EMG montage in early- and advanced-stage of PD and showed higher RWA in mentalis and flexor digitorum superficialis muscles and SINBAR EMG index in advanced-PD patients compared to patients in the early stage. Also, polysomnography-confirmed REM sleep behavior disorder was more common in advanced versus early-stage patients. Our findings suggest that RWA worsens or is more intense or more frequent with disease progression.

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.

Mastering nocturnal jigsaws in Parkinson's disease: a dusk-to-dawn review of night-time symptoms.

Finding out about night-time symptoms from Parkinson's disease (PD) patients can be a challenge as many patients and their carers cannot recall many symptoms that occur during the night, resulting in an under-recognition or a large variability of responses from clinical interviews and scales. Moreover, technology-based assessments for most night-time symptoms are still not universally available for use in a patient's home environment. Therefore, most physicians rely on their clinical acumen to capture these night-time symptoms based on pieces of patients' history, bedpartner's reports, clinical features, associated symptoms or conditions. To capture more night-time symptoms, the authors identified common nocturnal symptoms based on how they manifest from dusk to dawn with selected features relevant to PD. While some symptoms occur in healthy individuals, in PD patients, they may impact differently. The authors intend this narrative review to provide a practical guide on how these common night-time symptoms manifest and highlight pertinent issues by focusing on prevalence, clinical symptomatology, and specific relationships to PD. It is also important to recognise that PD-specific sleep disturbances increase with advancing disease with additional contributions from ageing, comorbidities, and medication side effects. However, the relative contribution of each factor to individual symptom may be different in individual patient, necessitating clinical expertise for individual interpretation. While there are debatable issues in certain areas, they underlie the complexity of night-time symptoms. Understanding night-time symptoms in PD is like re-arranging jigsaw pieces of clinical information to create, but never complete, a picture for physicians to instigate appropriate management.

Impaired ability to turn in bed in parkinson's disease as a potential rare cause of positional asphyxia: a sensor-based analysis.

BACKGROUND: Nocturnal hypokinesia commonly affects Parkinson's disease (PD) patients, manifesting primarily as an impaired ability to turn in bed and sleeping in specific positions, such as prone that potentially poses the risk of positional asphyxia. OBJECTIVE: To objectively evaluate, using axial inertial sensors (the NIGHT-Recorder), the ability of PD patients and controls to turn in bed from prone to supine position and to correlate these parameters with disease severity scores. PATIENTS AND METHODS: Turning in bed from prone to supine position was assessed in 16 PD patients with a moderate disease stage and 16 age-matched controls using the NIGHT-Recorder. Successful turning was defined as a full 180 ° turn from prone to supine position as evidenced by the NIGHT-Recorder. Objective parameters included duration, velocity, and acceleration of turn. The ability to turn in bed was determined by torque per kilogram body weight (T/kg). RESULTS: Two out of 16 PD patients (12.5%) could not initiate their turns. PD patients turned with a significant longer duration (p = 0.04), slower velocity (p = 0.04), and acceleration (p = 0.04) compared to controls. Although PD patients had lower T/kg than controls, the difference was not significant. Several significant correlations were demonstrated between turning parameters and clinical rating scales (Duration vs. UPDRS axial: r=0.51, p = 0.04; T/kg vs. PDSS-2: r=0.53, p = 0.03; T/kg vs. NHQ: r=0.52, p = 0.03). CONCLUSION: Our study provides objective evidence of impaired turning in bed from prone to supine position in PD patients with nocturnal hypokinesia. Appropriate measures should be taken to improve nocturnal mobility in those at risk.

More than hemifacial spasm? A case of unilateral facial spasms with systematic review of red flags.

Unilateral facial spasms (UFS) are frequently caused by hemifacial spasm (HFS), a disorder that usually results from vascular loop compression at the root exit zone of the facial nerve. However, UFS can also be a manifestation of other conditions, including brainstem tumours or demyelination, post-Bell's synkinesis, lesions of the facial nerve in the Faloppio canal and the parotid gland, dystonia, epilepsy, psychogenic conditions, tics and hemimasticatory spasm. In this report, we present a case of UFS, not due to HFS, highlighting clinical red flags for an alternative diagnosis. In addition, a systematic review was conducted to provide a comprehensive summary of UFS differential diagnoses with a list of red flags to assist neurologists in the evaluation of patients with UFS.

Evaluation of nocturnal hypokinesia in Parkinson's disease using a novel patient/proxy questionnaire and correlations with objective monitoring.

BACKGROUND: Nocturnal hypokinesia is a decreased ability to perform sufficient axial rotation and/or trunk flexion to turn in or get out of bed. Currently, there are no validated questionnaires specifically to assess nocturnal hypokinesia in PD patients. OBJECTIVE: To develop and validate a questionnaire to assess PD patients' problems associated with turning or getting out of bed. METHODS: The nocturnal hypokinesia questionnaire (NHQ) consists of 10 items, completed independently by patients and their caregivers. For validation, 76 patient-caregiver pairs completed the questionnaire and validity, agreement levels, and internal consistency assessed. In addition, 76 healthy couples served as controls. The NHQ and Modified Parkinson's Disease Sleep Scale (PDSS-2) were compared and 25 random patients-caregiver pairs were also assessed with objective night-time monitoring. RESULTS: Patient and caregiver scores showed a high level of agreement (Intra-class correlation: 0.84) with high internal consistency (KR-20 coefficient of 0.73 for patients and 0.69 for caregivers). No significant difference between the mean total NHQ scores as rated by patients and caregivers was observed. Mean NHQ scores from patients and caregivers were significantly higher than healthy controls (p < 0.001). Moderate correlations were found between the NHQ and PDSS-2 (r = 0.32, p = 0.004), and with objective monitoring (Number of turns: r = -0.41, p = 0.04, Degree of turn: r = -0.44, p = 0.02). CONCLUSION: The NHQ is a reliable instrument to identify symptoms of nocturnal hypokinesia amongst PD patients. Strong patient-caregiver agreement supports the use of proxy evaluation by caregivers when patient's information is unobtainable.

Red flags phenotyping: A systematic review on clinical features in atypical parkinsonian disorders.

To establish a clinical diagnosis of a parkinsonian disorder, physicians rely on their ability to identify relevant red flags, in addition to cardinal features, to support or refute their working diagnosis in an individual patient. The term 'red flag', was originally coined in 1989 to define the presence of non-cardinal features that may raise a suspicion of multiple system atrophy (MSA), or at least suggest alternative diagnosis to Parkinson's disease (PD). Since then, the term 'red flag', has been consistently used in the literature to denote the clinical history or signs that may signal to physicians the possibility of an atypical parkinsonian disorder (APD). While most red flags were originally based on expert opinion, many have gained acceptance and are now included in validated clinical diagnostic criteria of PD and APDs. The clinical appreciation of red flags, in conjunction with standard criteria, may result in a more accurate and earlier diagnosis compared to standard criteria alone. However, red flags can be clinical signs that are non-neurological, making the systematic assessment for them a real challenge in clinical practice. Here, we have conducted a systematic review to identify red flags and their clinical evidence in the differential diagnosis of common degenerative parkinsonism, including PD, MSA, progressive supranuclear palsy (PSP), corticobasal degeneration (CBD), and dementia with Lewy body (DLB). Increasing awareness and appropriate use of red flags in clinical practice may benefit physicians in the diagnosis and management of their patients with parkinsonism.

Exploring Bedroom Usability and Accessibility in Parkinson's Disease (PD): The Utility of a PD Home Safety Questionnaire and Implications for Adaptations.

BACKGROUND: Although bedrooms are identified as a major location for accidents among Parkinson's disease (PD) patients, there are no studies that specifically evaluate the bedroom environments of PD patients. OBJECTIVE: To examine the physical bedroom environment of patients with PD by generating a home safety questionnaire to rate bedroom accessibility and usability specifically for PD patients, and piloting it in a small set of PD patients, to identify environmental barriers and recommend adaptations to reduce accident risks. METHODS: Questionnaire development was based on the concept of Personal (P)-Environmental (E) fit. The P component covers five clinical domains that contribute to a patients' current state of health, including PD-related motor symptoms, PD-related non-motor symptoms, gait and balance impairments, comorbidities, and limitations on specific activities. The E component focuses on both indoor (bedroom, bathroom, living room, stairs, and kitchen), and outdoor (outdoor area and entrance) areas within a home where PD patients commonly get injured. Total score for the whole questionnaire is 171. A higher score indicates more P-E problems. RESULTS: Comprehension of questions was tested for content validity with an item-objective congruence index of above 0.6 for all items. High internal consistency (reliability) was confirmed by Cronbach's alpha coefficient of 0.828 (r). The pilot in five PD patients gave a mean total score of 48.2 ± 7.29 with a mean score on personal and environmental components of 16.8 ± 5.12 and 31.4 ± 4.51, respectively. CONCLUSION: This PD home safety questionnaire is a valid and reliable instrument for examining P-E problems by a multidisciplinary team during their home visits. More studies, involving a large number of PD patients, are needed to establish its utility as a screening instrument in PD patients to assess for home adaptations.

Can therapeutic Thai massage improve upper limb muscle strength in Parkinson's disease? An objective randomized-controlled trial.

Muscle weakness is a frequent complaint amongst Parkinson's disease (PD) patients. However, evidence-based therapeutic options for this symptom are limited. We objectively measure the efficacy of therapeutic Thai massage (TTM) on upper limb muscle strength, using an isokinetic dynamometer. A total of 60 PD patients with muscle weakness that is not related to their 'off' periods or other neurological causes were equally randomized to TTM intervention (n = 30), consisting of six TTM sessions over a 3-week period, or standard medical care (no intervention, n = 30). Primary outcomes included peak extension and flexion torques. Scale-based outcomes, including Unified Parkinson's Disease Rating Scale (UPDRS) and visual analogue scale for pain (VAS) were also performed. From baseline to end of treatment, patients in the intervention group showed significant improvement on primary objective outcomes, including peak flexion torque (F = 30.613, p < .001) and peak extension torque (F = 35.569, p < .001) and time to maximal flexion speed (F = 14.216, p = .001). Scale-based assessments mirrored improvements in the objective outcomes with a significant improvement from baseline to end of treatment of the UPDRS-bradykinesia of a more affected upper limb (F = 9.239, p = .005), and VAS (F = 69.864, p < .001) following the TTM intervention, compared to the control group. No patients reported adverse events in association with TTM. Our findings provide objective evidence that TTM used in combination with standard medical therapies is effective in improving upper limb muscle strength in patients with PD. Further studies are needed to determine the efficacy of TTM on other motor and non-motor symptoms in PD.

Impaired bed mobility: quantitative torque analysis with axial inertial sensors.

Difficulty in turning in bed is rated as the most troublesome night-time symptom among Parkinson's disease (PD) patients. AIM: To develop a practical objective method for home assessment of a patient's ability to turn in bed. METHODS: Nocturnal parameters and torque of self-turning in bed from 17 PD couples were assessed and compared using a wearable axial sensor for two nights in their homes. RESULTS: The torque of axial rotation which indicates the ability of PD patients to turn in bed was significantly less than their spouses (p < 0.001). Significant correlations were observed between the torque of turning in bed and total unified Parkinson's Disease Rating Scale score (r = 0.71; p = 0.001), and total Nocturnal Akinesia Dystonia and Cramp score (r = 0.634; p = 0.006). CONCLUSION: Our study confirms a decreased ability in turning in PD.

Rotigotine for nocturnal hypokinesia in Parkinson's disease: Quantitative analysis of efficacy from a randomized, placebo-controlled trial using an axial inertial sensor.

BACKGROUND: Nocturnal hypokinesia is a common symptom in Parkinson's disease (PD), negatively affecting quality of life of both patients and caregivers. However, evidence-based treatment strategies are limited. OBJECTIVE: To evaluate the efficacy of rotigotine transdermal patch, using a wearable sensor, in the management of nocturnal immobility. METHODS: 34 PD subjects with nocturnal immobility were randomized to receive rotigotine transdermal patch (mean ± SD of 10.46 ± 4.63 mg/24 h, n = 17) or placebo patch (n = 17). Treatment was titrated to an optimal dose over 1-8 weeks, then maintained for 4 weeks. Primary endpoints were objective parameters assessing axial rotation measured using an axial inertial sensor (the NIGHT-Recorder) over two nights at the patients' home. Scale-based assessments were also performed. RESULTS: There was a significant difference, in favor of rotigotine, in change from baseline score in the number of turns in bed (ANCOVA, p = 0.001), and degree of axial turn (p = 0.042). These objective improvements were mirrored by significantly greater improvements in clinical scale-based assessments, including the Unified Parkinson's Disease Rating Scale (UPDRS) total scores (p = 0.009), UPDRS-motor scores (p < 0.001), UPDRS-axial scores (p = 0.01), the Modified Parkinson's Disease Sleep Scale (p < 0.001), the Nocturnal Akinesia Dystonia and Cramp Scale (p = 0.003) and the eight-item PD Questionnaire (PDQ-8) scores (p = 0.01) from baseline to end of treatment in patients given rotigotine compared to placebo. CONCLUSION: We show that the rotigotine patch provides a significant improvement in nocturnal symptoms as assessed using both objective measures and clinical rating scales. The study demonstrates the feasibility of using wearable sensors to record objective outcomes in PD-related clinical trials.