Challenges of Teleneurology in the Care of Complex Neurodegenerative Disorders: The Case of Parkinson's Disease with Possible Solutions.

Teleneurology is a specialist field within the realm of telemedicine, which is dedicated to delivering neurological care and consultations through virtual encounters. Teleneurology has been successfully used in acute care (e.g., stroke) and outpatient evaluation for chronic neurological conditions such as epilepsy and headaches. However, for some neurologic entities like Parkinson's disease, in which an in-depth physical examination by palpating muscles and performing neurologic maneuvers is the mainstay of monitoring the effects of medication, the yield and feasibility of a virtual encounter are low. Therefore, in this prospective review, we discuss two promising teleneurology approaches and propose adjustments to enhance the value of virtual encounters by improving the validity of neurological examination: 'hybrid teleneurology', which involves revising the workflow of virtual encounters; and 'artificial intelligence (AI)-assisted teleneurology', namely the use of biosensors and wearables and data processing using AI.

Gender differences in diagnostic tools, medication, time to medication, and nonmotor symptoms in Parkinsonian patients.

BACKGROUND: Swedish National Quality Registers (NQRs) play an important role in collecting large amounts of diagnosis-specific data, symptoms, and treatments. The subset of data, Parkinson's Registry, has been in use for more than 20 years and represents all counties and hospitals in Sweden where neurological care is provided. OBJECTIVE: To study the differences between genders regarding diagnostic tools, pharmacological interventions, and self-reported symptoms in patients with symptoms originating from basal ganglia disease, either idiopathic or secondary Parkinsonism (PD). METHODS: PD-diagnosed patients from a mix of urban and rural locations were chosen from the NQR and sorted by gender. Self-reported, first-experienced PD-related symptoms defined the debut point of PD. RESULTS: In all, data from 1,217 patients were analyzed: 502 (41%) females/715 (59%) males. A total of 493 imaging investigations were performed, where of 239 (48% females/52% males) had a CT scan performed, 120 (24% females/29% males) had a dopamine transporter scans, and 134 (23% females/26% males) had a magnetic resonance imaging performed (Fisher's exact test, P = 0.19). The average time in years from symptom onset to start of first treatment, and from first to second added treatment was 2;7/2;9 (females) and 5;1/5;2 (males). Nonmotor symptoms were more prominent among males, especially in memory and gastrointestinal domains, including drooling and obstipation. Significantly more sexual problems were reported from males; 26% versus 7% (Fisher's exact test, P < 0.0001). CONCLUSIONS: Differences between genders were identified in this study. Sexual problems and cognitive decline were more frequent among males. More advanced diagnostic imaging techniques were performed among males. The time point for a second added medication was earlier for males than females.

Mediating effect of mutuality on caregiver burden in Parkinson's disease partners.

Objectives: Parkinson's disease (PD) is a complex neurodegenerative disorder with a broad list of motor and non-motor symptoms (NMS) that has been shown to affect the relationship quality (mutuality) and caregiver burden. However, little is known if the effect of motor and NMS on caregiver burden is mediated by mutuality. Therefore, the aim of this study was to explore if perceived mutuality by patients and partners mediates the effect of motor and NMS on caregiver burden.Methods: Data were collected from 51 dyads with one PD patient, including measures of motor signs, NMS, impaired cognition, patients' and partners' perceived mutuality, caregiver burden and dependency in activities in daily life (ADL). Structural equation model with manifest variables were applied to explore if patients' and partners' mutuality score mediated the effect of motor signs, NMS, ADL or impaired cognition on caregiver burden.Result: Our results suggest that having a partner with PD who is dependent in ADL or has impaired cognition decreases partners' mutuality which leads to elevated burden. Motor symptoms or other NMS were not associated with partners' mutuality or caregiver burden. Instead, increasing severity of motor symptoms decrease patients' mutuality in turn leading to lower level of partners' mutuality.Conclusion: Our findings enhance the understanding of the complexity of living with PD for the partner and suggest that clinical assessment should include evaluation of how PD symptoms influence the quality of the relationship between partners and patients.

Neuropathic Pain Prevalence of Older Adults in an Urban Area of Iran: A Population-Based Study.

BACKGROUND: Pain prevalence would increase as the population grows older, but the exact prevalence rate is not apparent in Iran. OBJECTIVES: This study, therefore, set out to reveal the prevalence of pain, especially neuropathic type and explore its associated comorbidities among Iranian older adults in a large urban population-based survey. METHODS: 5326 older people, aged ≥ 60 years, were randomly chosen by a multistage, cluster sampling method. The selected people then were interviewed by using the following instruments: a standard questionnaire about pain, questions of interview part of Douleur Neuropathique 4 Questions (DN4) and its comorbidities, GHQ-28, and a sociodemographic checklist. Descriptive statistics and multiple regression analysis were conducted to analyze the gathered data. RESULTS: The average of the participants' age was 68.92 ± 7.02 years. Of 5326 participants, 2529 (47.5%) of participants were male. About one-third of this population had chronic pain. Chronic neuropathic pain prevalence was 13.7% and nociceptive in 30%. Knee pain (20.6%) and feet dysesthesia (7.8%) were the most common sites of nociceptive and neuropathic pain, respectively. Results of multiple regression analysis revealed that the major comorbidities of chronic pain were osteoporosis, disability, diabetes mellitus, and stroke. Neuropathic pain experiences were significantly associated with GHQ-28 scores (t=-11.42, P<0.001). CONCLUSIONS: In addition to neuropathic pain, other subtypes of pain prevalence and the comorbidities are determined in the community-dwelling elder adults. This study highlights the importance of neuropathic pain and its adverse consequences and can be used to manage this populations' needs in Iran effectively.

Preoperative geriatric assessment and follow-up of patients older than 75 years undergoing elective surgery for suspected colorectal cancer.

OBJECTIVES: We investigated the predictive value of specific tools used in a Comprehensive Geriatric Assessment (CGA) with regard to postoperative outcome in patients 75 years and older undergoing elective colorectal cancer (CRC) surgery. Furthermore, recovery was followed over the first postoperative year using the same assessment tools. MATERIAL AND METHODS: Baseline clinical and CGA variables including functional and nutritional status, pressure sore risk, fall risk, cognition, depression, polypharmacy, comorbidity, and health-related quality-of-life (HRQoL) were prospectively recorded. Outcome variables were postoperative complications and length of stay (LOS). Patients were likewise followed up at one, three and twelve months postoperatively. RESULTS: Forty-nine patients underwent surgery (median age 81 years). Forty-three per cent had ASA (American Society of Anesthesiologists) class 2 47% had ASA class 3. Postoperative complications occurred in 32.7%. Median LOS was eight days. In univariate analyses, none of the parameters tested predicted postoperative complication or LOS. During follow-up, all patients recovered to baseline values apart from HRQoL which was still reduced at three and twelve months (p = .017). Nutritional status had improved twelve months after surgery (p = .011). CONCLUSIONS: No association could be found in this study between the results of a comprehensive geriatric assessment and prolonged length of stay or postoperative complication rate after elective surgery for colorectal cancer. Patients recovered well during the first year after surgery. Quality of life, however, was still lower than prior to surgery.

Mediating Effect of Mutuality on Health-Related Quality of Life in Patients with Parkinson's Disease.

The relationship quality, mutuality, has been identified as a protective factor in family care situations, but its role in mediating health-related quality of life (HRQoL) in patients having Parkinson's disease (PD) is not known. Data on patients' and partners' mutuality (MS), motor signs (UPDRS III), non-motor symptoms (NMSQuest), impaired cognition (IQCODE), dependency in activities of daily life (ADL), and HRQoL (PDQ8) were collected from 51 dyads. Structural equation model with manifest variables was applied to explore if the MS score mediated the effect of UPDRS III, NMSQuest, IQCODE, and dependency in ADL on PDQ8. The results suggest that increasing severity of motor and non-motor symptoms decreases patients' mutuality which leads to worse HRQoL. Partners' mutuality mediated the effect of impaired cognition which in turn decreased patients' mutuality. The findings enhance our understanding of how various symptoms may influence PD patients' HRQoL. This may help clinicians to personalize interventions to provide more effective interventions to improve the lives of patients with PD.

The diagnostic accuracy of median nerve ultrasonography in elderly patients with carpal tunnel syndrome: sensitivity and specificity assessment.

BACKGROUND: Accurate diagnosis of carpal tunnel syndrome (CTS), the most common entrapment neuropathy, and its differentiation from other diseases are essential, especially in older individuals with advanced symptoms and modified electrophysiological abnormalities. The current study was conducted to evaluate the diagnostic accuracy of ultrasonography (US), regarding sensitivity and specificity in the diagnosis of CTS in elderly patients. METHODS: Individuals with upper limb complaints and reference subjects were recruited from the Rofaydeh Hospital, Tehran, Iran, from June 2013 to October 2014 - (15 months). We evaluate case and control subjects for health status, demographics, clinical characteristics of CTS, median nerve physiology by electrodiagnostic tests, and anatomy by US. Median nerve cross-sectional area (CSA) at precanal, tunnel inlet, midcanal, tunnel outlet, and antecubital levels was measured applying US examination. RESULTS: Of the 723 complaining patients, we assessed 380 patients with CTS symptoms. Electrodiagnostic studies (EDX) confirmed the CTS diagnosis in 203 of these clinically diseased patients. A total of 103 patients (of the 113 reference subjects) had normal EDX in the reference group. Comparisons of wrists between the afflicted and reference subjects demonstrated the CSA at precanal, tunnel inlet, midcanal, and tunnel outlet levels being significantly more abundant in the diseased hands than in the nondiseased hands. CSA at the tunnel inlet and the inlet-to-antecubital CSA ratio with a threshold of 8.5 mm2 and 0.65 gave the best diagnostic accuracy with a sensitivity and specificity of 96.9 and 93.6% for the inlet CSA and 99 and 28% for the CSA ratio, respectively. CONCLUSION: The US as a noninvasive diagnostic method may serve for the investigation of CTS in elderly patients with excellent sensitivity and specificity.

No Significant Difference in Cognitive Decline and Mortality between Parkinson's Disease Dementia and Dementia with Lewy Bodies: Naturalistic Longitudinal Data from the Swedish Dementia Registry.

BACKGROUND: Whether dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD) are distinct disorders or two subtypes of the same entity, is not yet fully understood. There is a dearth of knowledge on differences in longitudinal clinical outcomes between DLB and PDD. OBJECTIVE: We aimed to compare longitudinal trend of cognitive decline, mortality, and their determinant factors between patients with DLB and PDD. METHODS: At baseline, we recruited 1110 DLB, and 764 PDD patients registered in the Swedish dementia registry (SveDem) during 2007-2015. Cognitive status was assessed at baseline and each follow-up visit by mini-mental state examination (MMSE). At least one follow-up MMSE was available for 411 (37.0%) DLB and 229 (30.0%) PDD patients. Rate of cognitive decline and mortality risk were compared between the two groups. RESULTS: After an average of 2-years, the rate of cognitive decline did not differ between DLB (1.1 MMSE unit/year) and PDD (1.2 MMSE unit/year) groups (p = 0.970). There was no significant difference in the median survival time between DLB (4.0 years) and PDD (4.1 years) groups (Log rank p = 0.614). Antipsychotic drug use in DLB and larger number of medications in PDD were the most important determinants of faster annual cognitive decline. CONCLUSIONS: Our findings from real-world clinical practice demonstrated that the rate of cognitive decline and mortality do not differ significantly between DLB and PDD at least over 2 years, yet, various factors might determine clinical outcome in these two groups. It seems that DLB and PDD are probably similar synucleinopathies, with phenotypical variations in the order of manifestations rather than course of progression and clinical outcome.

Sensitivity of high-resolution ultrasonography in clinically diagnosed carpal tunnel syndrome patients with hand pain and normal nerve conduction studies.

BACKGROUND: Suspecting carpal tunnel syndrome (CTS) in patients with hand pain is usual. Considering the variable rate of false-negative results in nerve conduction study (NCS), as a frequent reference confirmatory standard test, we aimed to evaluate the diagnostic accuracy of neuromuscular ultrasound in patients with clinical evidence of CTS and normal NCS. METHODS: It was a diagnostic accuracy study conducted in the outpatient clinic of Rofaydeh Hospital, Tehran, Iran, between July 2012 and December 2016; it recruited clinically diagnosed CTS patients and a control group. All participants underwent comprehensive clinical examination, NCS, and high-resolution ultrasonography of the median nerve. RESULTS: Two hundred and fifty patients with clinical evidence of CTS met the inclusion criteria, of whom 103 (27.1%) had normal NCS and underwent an ultrasound examination. A cutoff point of 9.4 mm2 (mean + 2 standard deviation) for median nerve cross-sectional area at the carpal tunnel inlet from the control group was set to detect 73% abnormality in the case group. CONCLUSION: Ultrasonography had a sensitivity rate of 73% in patients with clinical CTS and negative NCS, increasing the overall diagnostic sensitivity for clinically suspected CTS in the electrodiagnostic lab setting to 92%. The study highlights the complementary role of ultraso-nography in diagnosing CTS in conjunction with NCS.

The older patient's experience of the healthcare chain and information when undergoing colorectal cancer surgery according to the enhanced recovery after surgery concept.

AIMS AND OBJECTIVES: To describe how older patients experience the healthcare chain and information given before, during and after colorectal cancer surgery. BACKGROUND: Most persons with colorectal cancer are older than 70 years and undergo surgery with subsequent enhanced recovery programmes aiming to quickly restore preoperative function. However, adaptation of such programmes to suit the older patient has not been made. DESIGN: Qualitative descriptive study. METHOD: Semi-structured interviews were conducted on 16 patients undergoing colorectal cancer surgery at a Swedish University Hospital. The inductive content analysis was employed. RESULTS: During the period of primary investigation and diagnosis, a paucity of information regarding the disease and management, and lack of help in coping with the diagnosis of cancer and its impact on future life, leads to a feeling of vulnerability. During their stay in hospital, the patient's negative perception of the hospital environment, their need for support, and uncertainty and anxiety about the future are evident. After discharge, rehabilitation is perceived as lacking in structure and individual adaptation, leading to disappointment. Persistent difficulty with nutrition delays recovery, and confusion regarding division of responsibility between primary and specialist care leads to increased anxiety and feelings of vulnerability. Information on self-care is perceived as inadequate. Furthermore, provided information is not always understood and therefore not useful. CONCLUSION: Information before and after surgery must be tailored to meet the needs of older persons, considering the patient's knowledge and ability to understand. Furthermore, individual nutritional requirements and preoperative physical activity and status must be taken into account when planning rehabilitation. RELEVANCE TO CLINICAL PRACTICE: Patient information must be personalised and made understandable. This can improve self-preparation and participation in the own recovery. Special needs must be addressed early and followed up.

Different doses of steroid injection in elderly patients with carpal tunnel syndrome: a triple-blind, randomized, controlled trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is commonly seen in elderly populations, in part due to increased presence of predisposing comorbidities as well as physiological changes. We aimed at comparing the effectiveness of different doses of steroid using the ultrasound-guided hydrodissection method in elderly patients with CTS. METHODS: We conducted a prospective, triple-blind, randomized, controlled trial in elderly patients with CTS. Patients were allocated to one of three groups by simplified randomization. Groups I-III received 80 mg triamcinolone (2 mL) and 1 mL of 2% lidocaine; 40 mg triamcinolone (1 mL), 1 mL of 2% lidocaine, and 1 mL normal saline; and 1 mL of 2% lidocaine and 2 mL normal saline, respectively to make up to 3 mL volume. A wrist splint was then applied for support. Outcome measures included the visual analog scale (VAS) and the Boston Carpal Tunnel Questionnaire, and median motor and sensory nerve conduction and its sonographic inlet cross-sectional area were used as objective measures. All data were recorded at baseline and 2, 12, and 24 weeks after injection. The investigators, patients, and statistician were blinded to the treatment assignment. RESULTS: In total, 161 patients were recruited without statistically significant demographic differences between the three groups. There were no statistically significant differences between groups in any outcome, with the exception of the median distal motor latency, which was greater in Group II at all three follow-up visits, and significant baseline VAS difference between Groups I and III. CONCLUSION: Hydrodissection with lidocaine and normal saline is as effective as hydrodissection with low- and high-dose steroid medication in elderly patients with CTS in this study, but further studies with matched baseline measures and also a sham group are suggested for definitive recommendation.

Evolution of Orofacial Symptoms and Disease Progression in Idiopathic Parkinson's Disease: Longitudinal Data from the Jönköping Parkinson Registry.

BACKGROUND: Orofacial symptoms are common in Parkinson's disease (PD) both as initial manifestations and late markers of disease complications. We aimed to investigate the evolution of orofacial manifestations and their prognostic value throughout PD progression. METHODS: Data was obtained from "Jönköping Parkinson Registry" database on routine care visits of 314 people with idiopathic PD in southern Sweden. Information on baseline symptomatology, orofacial features, UPDRS, and medications was recorded at baseline and during each follow-up visit within an average of 4.2 (range: 1-12) years. RESULTS: Hypomimia, affected speech, drooling, and impaired swallowing were present in 37.3%/91.6%, 14.1%/65.5%, 11.7%/55.3%, and 10.2%/34.5% at baseline/follow-up, respectively. Male sex [OR = 2.4 (95% CI: 1.0-5.9)], UPDRS motor scores [OR = 1.2 (95% CI: 1.1-1.3)], dominant rigidity [OR = 5.2 (95% CI: 1.4-19.1)], and autonomic disturbance [OR = 3.4 (95% CI: 1.1-10.9)] were risk factors for drooling. Individuals with more severe orofacial burden at baseline had shorter median time to develop UPDRS-Part III > 28 [3rd tertile = 4.7 yr, 2nd tertile = 6.2 yr, and 1st tertile = 7.8 yr; p = 0.014]. CONCLUSIONS: Majority of people with PD manifest orofacial manifestations at either early or late stages of the disease. PD severity, symmetry of motor disturbances, and autonomic disorders correlate with orofacial symptoms. Individuals with more severe orofacial burden at baseline progressed faster to more advanced stages.

Hyperechogenicity of substantia nigra for differential diagnosis of Parkinson's disease: A meta-analysis.

Studies have suggested that the majority of patients with Parkinson's disease have abnormal ultrasound hyperechogenicity of the substantia nigra, and that this may be useful in diagnosis. We performed a systematic review and meta-analysis to evaluate diagnostic value of substantia nigra ultrasound to differentiate Parkinson's disease from atypical parkinsonism and from essential tremor. We systematically searched PubMed and EMBASE for relevant studies published until November 2016. Eligible articles were screened, data were extracted and study quality was scored by two independent reviewers. We applied random effect models to calculate pooled estimates for the prevalence of hyperechogenicity in each condition. For final meta-analysis, 71 articles with a total number of 5730 participants (idiopathic Parkinson's disease: 4494, atypical parkinsonism: 594, essential tremor: 642) were included. The pooled prevalence rate of hyperechogenicity was 84% (95 %CI 80-87%) in idiopathic Parkinson's disease, 28% (95% CI 20-36%) in atypical parkinsonism and 15% (95% CI 7-23%) in essential tremor. Based on our meta-analysis, substantia nigra hyperechogenecity has 75% (95% CI: 60-86%) sensitivity and 70% (95% CI: 55-81%) specificity to differentiate idiopathic Parkinson's disease from atypical parkinsonism. Sensitivity and specificity to distinguish idiopathic Parkinson's disease from essential tremor was calculated as 78% (95% CI: 69-85%) and 85% (95% CI: 77-91%), respectively. Findings from our meta-analysis showed that transcranial sonography can provide useful information to differentiate idiopathic Parkinson's disease from mimicking movement disorders, although sensitivity and specificity are suboptimal, particularly for differentiating from atypical parkinsonism.

Assessing postural balance in early Parkinson's Disease-validity of the BDL balance scale.

BACKGROUND: There is a need for a valid assessment test of balance in early Parkinson's disease (PD). OBJECTIVE: To validate the Bäckstrand Dahlberg Liljenäs Balance Scale (BDL), a test of balance performance constructed to assess mild to moderate balance disability due to neurological disease, for use in persons with early PD. METHODS: Cross-sectional psychometric evaluation study from a convenience sample community-dwelling persons with PD (n = 28). MAIN MEASURES: The BDL was validated using the Berg Balance Scale (BBS), the motor part of the Unified Parkinson's Disease Rating Scale (mUPDRS), the Timed Up and Go (TUG) and Timed Up and Go-cognition (CTUG). Correlations were calculated by Spearman's rank correlation coefficient (rho). Rasch analyses were used to test the internal construct of the BDL. The result from the BDL was compared to a healthy reference group. RESULTS: The correlation between the BDL and the BBS (rho = 0.703) was high positive, while for mUPDRS (rho = -0.280), TUG (rho = -0.321) and CTUG (rho = -0.361) the correlations with the BDL were negligible to low negative. The Rasch analyses for the BDL showed a good distribution of the task difficulties with neither ceiling nor floor effect among individual measures. There was a significant difference (p = 0.03) in performance of the BDL between the PD group and the healthy reference group. CONCLUSIONS: The BDL Balance Scale can be considered a valid clinical assessment test when evaluating balance training interventions in persons with early PD. It can be recommended as an outcome measure in clinical practice and in clinical research within this population.

Determinants of Dyadic Relationship and Its Psychosocial Impact in Patients with Parkinson's Disease and Their Spouses.

The caregiver-care receiver relationship (mutuality) in Parkinson's disease (PD) and its association with motor and non-motors symptoms, health-related quality of life (HRQoL), and caregiver burden have not fully been investigated. The aim of our study was to explore if (1) the level of mutuality perceived by PD-patients and PD-partners differs, (2) different factors are associated with perceived mutuality by PD-patients and PD-partners, and (3) mutuality is associated with PD-patients health-related quality of life (HRQoL) and caregiver burden. We collected data on motor signs (UPDRS III), non-motor manifestations (NMSQuest), PD-patients' cognition (IQCODE), mutuality scale (MS), PD-patients' HRQoL (PDQ8), and caregiver burden (CB) from 51 PD dyads. Predictors were identified using multivariate regression analyses. Overall, the dyads rated their own mutuality as high with no significant difference between the dyads except for the dimension of reciprocity. PD-patients' MS score (p = .001) and NMSQuest (p ≤ .001) were significant predictors of PDQ8. Strongest predictor of CB was PD-partners' MS score (<.001) and IQCODE (p = .050). In general, it seems that non-motor symptoms contribute to a larger extent to the mutual relationship in PD-affected dyads than motor disabilities.

Prevalence and associated comorbidities of restless legs syndrome (RLS): Data from a large population-based door-to-door survey on 19176 adults in Tehran, Iran.

BACKGROUND: Discrepancies have been reported in the prevalence rate of restless legs syndrome (RLS) among different ethnic groups and geographic populations. Furthermore, there are disagreements on determinant factors and associated comorbidities of RLS. We aimed to estimate prevalence of RLS and investigate its associated comorbid conditions and risk factors in a large population-based door-to-door survey. METHODS: Following a multistage random sampling from the households lived in 22 urban districts of Tehran, Iran, 19176 participants with ≥30 years of age were recruited. Trained surveyors filled study checklist consisting of baseline characteristics, risk factors and comorbidity profile and the International RLS Study Group (IRLSSG) diagnostic criteria through face-to-face interviews. RESULTS: In total, 1580 individuals were positively screened for RLS resulting in a standardized prevalence rate of 60.0/1000. There was a gradual increase in RLS prevalence by advancing age, however, sex difference disappeared after adjustment. Parkinsonism [adjusted odds' ratio (adj-OR) = 7.4 (95% CI: 5.3-10.4)], peripheral neuropathy [adj-OR = 3.7 (95% CI: 3.3-4.1)], subjective cognitive impairment (SCI) [adj-OR = 3.1 (95% CI: 2.7-3.4)], acting out dreams [adj-OR = 2.8 (95% CI: 2.5-3.2)], hyposmia [adj-OR = 2.5 (95% CI: 2.2-2.9)], active smoking [adj-OR = 1.5 (95% CI: 1.3-1.9)] and additional number of cardiometabolic diseases associated with higher risk of RLS [adj-OR = 1.6 (95% CI: 1.2-2.3)]. CONCLUSION: Our findings showed that neuro-cognitive co-morbidities such as parkinsonism, peripheral neuropathy, SCI, acting out dreams and hyposmia as well as cardio-metabolic risk factors and diseases were independent determinants of RLS. It is recommended to screen individuals with either these comorbid conditions for RLS or the ones with RLS for the accompanying diseases.

Sexual dimorphism in Parkinson's disease: differences in clinical manifestations, quality of life and psychosocial functioning between males and females.

INTRODUCTION: Sex-related differences in clinical manifestations and consequences of Parkinson's disease (PD) have been poorly explored. Better understanding of sexual dimorphism in neurologic diseases such as PD has been announced as a research priority. The aim of our study was to determine independent sex differences in clinical manifestations and subtypes, psychosocial functioning, quality of life (QoL) and its domains between male and female individuals with PD. PATIENTS AND METHODS: A comprehensive list of demographics, motor symptoms and subtypes, nonmotor features, health-related quality of life (HRQoL), psychosocial functioning and general aspects of daily life was assessed in 157 individuals (108 males and 49 females) with idiopathic PD. In order to control for potential confounding variables, we applied Orthogonal Partial Least Squares - Discriminant Analysis (OPLS-DA) to explore the strength of each feature to discriminate male and female patients with PD. RESULTS: While no sex difference was found in the total Unified Parkinson's Disease Rating Scale (UPDRS) score and cumulative daily dose of levodopa, females had significantly more severe anxiety (mean difference =2.2 [95% confidence interval, CI: 0.5-4.0], P=0.011), worse nutritional status (23.8 [standard deviation, SD =4.2] vs 25.8 [SD =2.6], P=0.003) and poorer QoL (28.3 [SD =15.7] vs 17.9 [SD =14.2], P<0.001). Based on multivariate discriminant analysis, emotional well-being, bodily discomfort, social support, mobility and communication domains of HRQoL, together with anxiety, depression and psychosocial functioning, were the strongest features with more severe/worse status in females after adjustment for potential statistical confounders. CONCLUSION: Our study provides a comprehensive understanding of sexual dimorphism in PD. Anxiety, depression, specific domains of HRQoL (mobility, emotional well-being, social support and bodily discomfort) and psychosocial functioning were significantly worse in female individuals with PD. Sexual dimorphism in PD highlights the features that are more likely to be affected in each sex and should be specifically targeted when managing male and female individuals with PD.

Pre- and unplanned walking turns in Parkinson's disease - Effects of dopaminergic medication.

Although dopaminergic medication improves functional mobility in individuals with Parkinson's disease (PD), its effects on walking turns are uncertain. Our goals was to determine whether dopaminergic medication improves preplanned and unplanned walking turns in individuals with PD, compared to healthy controls. Nineteen older adults with mild-to-moderate PD and 17 healthy controls performed one of the following three tasks, presented randomly: walking straight, or walking and turning 180° to the right or left. The walking direction was visually cued before starting to walk (preplanned) or after (unplanned, i.e., 0.6m before reaching the turning point). Subjects with PD were assessed off dopaminergic medication (OFF) and on dopaminergic medication (ON) medication. Turning strategy (step and spin turns), turning performance (turning distance and body rotation) and walking pattern were analyzed for three turning steps. Irrespective of medication state and turning condition, step and spin turns followed a nearly 50:50 distribution. After intake of dopaminergic medication, subjects with PD increased their turning distance but not the amount of body rotation or their walking pattern. Compared to controls, turning impairments in subjects with PD remained while ON medication and problems regulating step width were the most prominent features of their walking pattern. Specifically, subjects with PD turned with narrower cross-over steps, i.e. when the external foot crossed over the line of progression of the internal leg. We conclude that turning impairments remained even after dopaminergic medication and problems modulating step width appears to be a critical feature for turning in PD.

Pain management in patients with Parkinson's disease: challenges and solutions.

This review focuses on the diagnosis and management of Parkinson-related pain which is one of the more frequently reported nonmotor symptoms in Parkinson's disease (PD), which is the second most common neurodegenerative disease after Alzheimer's disease. Pain is ranked high by patients as a troublesome symptom in all stages of the disease. In early-stage PD, pain is rated as the most bothersome symptom. Knowledge of the correct diagnosis of pain origin and possible methods of treatments for pain relief in PD is of great importance. The symptoms have a great negative impact on health-related quality of life. Separating PD-related pain from pain of other origins is an important challenge and can be characterized as "many syndromes under the same umbrella". Among the different forms of PD-related pain, musculoskeletal pain is the most common form, accounting for 40%-90% of reported pain in PD patients. Augmentation by pathophysiological pathways other than those secondary to rigidity, tremor, or any of the other motor manifestations of the disease seems most probable. In PD, the basal ganglia process somatosensory information differently, and increased subjective pain sensitivity with lower electrical and heat-pain thresholds has been reported in PD patients. The mechanism is assumed to be diminished activity of the descending inhibitory control system of the basal ganglia. PD pain, like many of the nonmotor symptoms, remains underdiagnosed and, thus, poorly managed. A systematic collection of patient descriptions of type, quality, and duration of pain is, therefore, of utmost importance. Recent studies have validated new and more specific and dedicated pain scales for PD-related symptoms. Symptomatic treatments based on clinical pain classification include not only pharmacological but also nonpharmacological methods and, to some degree, invasive approaches. In the clinic, pharmacological and nonpharmacological interventions can be effective to varying degrees - as single therapies or in combination - and should be employed, because no therapeutic strategies have been validated to date for managing PD pain. Multimodal approaches should always be considered, dopamine replacement therapies should be adjusted, and analgesics and/or antidepressants should be considered, including the use of different forms of complementary therapies.