The effects of standard and modified LSVT BIG therapy protocols on balance and gait in Parkinson's disease: A randomized controlled trial.

BACKGROUND: Lee Silverman voice treatment (LSVT) BIG is an exercise program developed for patients with Parkinson's disease (PwPD), consisting of sets of exercises performed for 4 consecutive days a week for 4 weeks. However, the standard protocol suggests a treatment frequency difficult to follow for most patients who have difficulties reaching rehabilitation clinics. Our aim was to compare the standard LSVT BIG protocol with a modified LSVT (m-LSVT) BIG protocol (twice a week in the clinic for 4 weeks and twice a week at home for 4 weeks). METHODS: In this randomized controlled trial, 16 PwPD (aged 18-80 years, Hoehn and Yahr stages I-III) were recruited into two groups. The LSVT group received standard LSVT BIG training (four times per week for 4 weeks at the clinic). The other group was given m-LSVT BIG exercises, but unlike the LSVT group, the m-LSVT group exercised twice a week at the clinic and twice a week at home for 4 weeks. The Berg Balance Scale was used to assess functional balance. Biodex Balance System was used to assess laboratory balance measures. Timed Up and Go test and G-Walk sensor system were used to assess functional mobility and spatiotemporal gait analysis. RESULTS: Significant group-by-time interactions on the eyes open-firm surface score of the modified clinical test of sensory integration of balance (F = 10.138, p = .007) and gait cycle symmetry index (F = 10.470, p = .010) were found to be in favor of the LSVT group. Additionally, post hoc analyses revealed that both groups significantly improved postural stability, gait speed, motor symptoms, and functional mobility (p < .05). CONCLUSION: The results revealed the beneficial effects of the modified protocol on balance and gait in PwPD, as well as the superiority of the standard LSVT BIG protocol. The m-LSVT BIG protocol may be an effective intervention method, especially for PwPD who have difficulty adapting to the treatment frequency of the standard protocol.

Characterizing Camptocormia in Parkinson's Disease Using Muscle Ultrasonography.

BACKGROUND: Camptocormia (CC) is the forward-bending of the spine of more than 30 degrees that can be found in Parkinson's disease (PD) as a disabling complication. Detection of changes in paraspinal lumbar musculature in CC is of value for choosing treatment strategies. OBJECTIVE: To investigate whether these changes can be detected using muscle ultrasonography (mUSG). METHODS: Age and sex-matched groups comprised 17 PD patients with CC (seven acute, PD-aCC; 10 chronic PD-cCC), 19 PD patients with no CC, and 18 healthy controls (HC). Lumbar paravertebral muscles (LPM) on both sides were assessed using mUSG by two different raters blinded to the group assignment. Groups were compared with regard to the linear measurements of the muscle thickness as well as semi-quantitative and quantitative (grayscale) analyses of muscle echogenicity using a univariate general linear model. RESULTS: All assessments showed substantial interrater reliability. The PD-cCC group had significantly thinner LPM compared to groups with no CC (PD and HC). Groups of PD-aCC and PD-cCC differed from the groups of no CC in quantitative and semi-quantitative analyses of LPM echogenicity, respectively. CONCLUSION: Assessment of LPM in PD patients with CC can be reliably performed using mUSG. Also, mUSG may be used as a screening tool to detect CC-related changes in thickness and echogenicity of the LPM in patients with PD.

Cross-Cultural Differences in Stigma Associated with Parkinson's Disease: A Systematic Review.

BACKGROUND: Stigma is an important social attitude affecting the quality of life (QoL) of people with Parkinson's disease (PwP, PD) as individuals within society. OBJECTIVE: This systematic review aimed to 1) identify the factors associated with stigma in PD and 2) demonstrate culture-based diversity in the stigmatization of PwP. We also reported data from the Turkish PwP, which is an underrepresented population. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, a literature search of the PubMed/Medline electronic database was performed covering the last 26 years. Articles on self-perceived stigma in PD with a sample size >  20 and quantitative results were included. Data were extracted by independent reviewers. RESULTS: After screening 163 articles, 57 were eligible for review, most of which were from Europe or Asia. Only two studies have been conducted in South America. No study from Africa was found. Among the 61 factors associated with stigma, disease duration, sex, and age were most frequently studied. A comparison of the investigated factors across the world showed that, while the effect of motor impairment or treatment on stigma seems to be culture-free, the impact of sex, education, marriage, employment, cognitive impairment, and anxiety on stigma may depend on culture. CONCLUSION: The majority of the world's PD population is underrepresented or unrepresented, and culture may influence the perception of stigma in PwP. More diverse data are urgently needed to understand and relieve the challenges of PwP within their society.

The effect of task-oriented circuit training-based telerehabilitation on upper extremity motor functions in patients with Parkinson's disease: A randomized controlled trial.

INTRODUCTION: Upper extremity functions are impaired in patients with Parkinson's disease (PwPD), which leads to difficulties in activities of daily living (ADL), such as reaching or handwriting. The aim of this study was to investigate the effectiveness of task-oriented circuit training-based telerehabilitation (TOCT-TR) on the upper extremity motor function in PwPD. METHODS: In this randomized controlled trial (RCT) 30 PwPD (aged 45-70 years, Hoehn & Yahr stage I-III) were recruited and randomly allocated into two groups. The TOCT-TR group received home training through video sessions three days/week for six weeks. Additionally, both the TOCT-TR group and the control group (CG) underwent home exercises aimed at improving balance, gait, and mobility three days/week for six weeks. The primary outcome measure was upper extremity motor functions measured with the Nine Hole Peg test (9-HPT), the Jebsen Hand Function Test (JHFT), grip strengths, pinch strengths, and the Unified Parkinson's Disease Rating Scale-III (UPDRS-III). Secondary outcome measures included the UPDRS-II and the quality of life (QoL, PDQ-8). RESULTS: This study showed significant group-by-time interactions on the 9-HPT (p < 0.001), the JHFT (p < 0.001), grip strengths (p < 0.001), pinch strengths (p ≤ 0.015), and the UPDRS-III (p = 0.007) in favor of the TOCT-TR. Additionally, the UPDRS-II (p < 0.001), and the PDQ-8 (p = 0.005) improved in both groups. CONCLUSION: This is the first RCT showing that the TOCT-TR improved upper extremity motor functions, ADL, and QoL in PwPD. The TOCT-TR may help improve the upper extremities of PwPD who have difficulties reaching rehabilitation clinics.

Risk disclosure in prodromal Parkinson's disease - A survey of neurologists.

INTRODUCTION: In the absence of a disease-modifying treatment and prognostic uncertainty, ethics of risk disclosure in prodromal Parkinson's disease (PD) is challenging. Previous studies highlighted several facets of these challenges from the perspective of involved parties. However, to date, the view of neurologists who may encounter individuals with prodromal PD remained unrepresented. Moreover, cross-cultural differences intrinsic to the ethics of risk disclosure are yet to be elucidated. Therefore, we investigated the attitude of neurologists toward risk disclosure in prodromal PD. METHODS: In this observational study, Turkish neurologists were invited to fill out a questionnaire evaluating their stance on risk disclosure regarding an individual with polysomnography-confirmed REM sleep behavior disorder, which is the strongest risk factor for PD. RESULTS: More than 90% of the participating 222 neurologists were familiar with prodromal PD. While 15.3% stated that the risk should be disclosed in any case, 6.8% chose no disclosure. The remaining 77.9% favored disclosure only under certain circumstances, the plurality of which was the individual's consent to know about the risk. After reminding the potential neuroprotective effects of exercise and diet, neurologists who chose the option of "no disclosure" decreased to 3.2% (McNemar's test p = 0.008). No significant differences among the neurologists were found regarding sex, academic title, or field of interest. CONCLUSION: The majority of the neurologists found it appropriate to disclose the risk of future PD only if the individual expresses a desire to know. Also, recognition of the impact of lifestyle factors on PD is important in prognostic counseling.

Botulinum toxin injections in jaw-opening dystonia. The lateral pterygoid - maxillary artery problem.

It has been suggested that the variations in the trajectory of the maxillary artery (MA) near the lateral pterygoid muscle (LPM) play a critical role in Botulinum neurotoxin (BoNT) injections in patients with jaw-opening/deviation dystonia (JOD). In the case of a lateral course to the LPM, an extraoral injection entails risks of MA injury, pain, and hematoma. Previous reports suggest geographical differences in variations of the MA-LPM relationship. We aimed to determine these variations in Turkish individuals and highlight the need to establish a consensus on approach to LPM injections. In 284 individuals, contrast-enhanced magnetic resonance angiography (MRA) images were evaluated by two radiologists on both sides for the variations in the course of the MA in the infratemporal fossa. Images of 44 were excluded due to trauma, arteriovenous malformation, mass, surgery, and imaging artifacts. Of the included, 62.1% were female. In 480 evaluations of 240 individuals, the MA passed lateral to the LPM in 65.6% (n = 315). No sex difference was noted. In 51 individuals (21.3%), the MA course differed on the right and left sides (medial-lateral asymmetry). These results confirm that the lateral course of the MA is more frequent. In patients with JOD, the trajectory of the MA should be determined with imaging prior to extraoral BoNT injections. In the case of a lateral course, an intraoral approach seems to be safer to avoid a potential MA injury.

Intermittent Subcutaneous Injections of Apomorphine in Parkinson's Disease.

The intermittent subcutaneous injection of apomorphine is highly effective in the management of motor and non-motor symptoms of Parkinson's disease. Although it has been shown that apomorphine injection can be safely used in selected cases at all stages of the disease, there is no consensus regarding intermittent administration strategies. This review aimed to discuss the indications for intermittent subcutaneous apomorphine use in clinical practice, possible side effects and their management, and contraindicated cases in light of the literature and to present practical recommendations for clinical practice.

Impaired Executive Function and Depression as Independent Risk Factors for Reported Delirium Symptoms: An Observational Cohort Study Over 8 Years.

BACKGROUND: Acute medical illnesses, surgical interventions, or admissions to hospital in older individuals are frequently associated with a delirium. In this cohort study, we investigated the impact of specific cognitive domains and depression before the occurrence of delirium symptoms in an 8-year observation of older non-hospitalized individuals. METHODS: In total, we included 807 participants (48-83 years). Deficits in specific cognitive domains were measured using the CERAD test battery, and depressive symptoms were measured using Beck Depression Inventory and the Geriatric Depression Scale (GDS) before the onset of a delirium. Delirium symptoms were retrospectively assessed by a questionnaire based on the established Nursing Delirium Screening Scale. RESULTS: Fifty-eight of eight hundred seven participants (7.2%) reported delirium symptoms over the 8-year course of the study. Sixty-nine percent (n = 40) of reported delirium symptoms were related to surgeries. In multivariate regression analysis, impaired executive function was an independent risk factor (p = 0.034) for the occurrence of delirium symptoms. Furthermore, age (p = 0.014), comorbidities [captured by the Charlson Comorbidity Index (CCI)] (p < 0.001), and depression (p = 0.012) were significantly associated with reported delirium symptoms. CONCLUSION: Especially prior to elective surgery or medical interventions, screening for impaired executive function and depression could be helpful to identify patients who are at risk to develop delirium symptoms.

Screen Fast, Screen Faster: A Pilot Study to Screen for Depressive Symptoms Using the Beck Depression Inventory Fast Screen in Parkinson's Disease With Mild Cognitive Impairment.

Objective: Depressive symptoms have a high prevalence in patients with Parkinson's disease (PD) and are associated with cognitive dysfunction. Especially in PD with mild cognitive impairment (MCI), a time-efficient and valid instrument for the assessment of depression primarily focusing on psychological symptoms and disregarding confounding somatic symptoms is needed. We performed an examination of the psychometric properties of the Beck Depression Inventory II (BDI-II) and the Beck Depression Inventory Fast Screen (BDI-FS). Methods: The sample consisted of 64 patients [22 females and 42 males, mean age: 67.27 years (SD = 7.32)]. Depressive symptoms were measured in a cohort of PD patients with MCI. For the BDI-II and BDI-FS the psychometric concepts of internal consistency, convergent validity and diagnostic agreement were assessed. Results: Patients gave higher ratings on test items addressing somatic symptoms than those addressing non-somatic ones. The correlation between the absolute total scores of the BDI-II and the BDI-FS was significant (r = 0.91, p < 0.001), which indicated convergent validity. The Cronbach's alpha values indicated adequate internal consistencies for both measures (BDI-II: 0.84; BDI-FS: 0.78). There was a higher than chance level agreement of diagnoses of the two questionnaires, measured by Cohen's kappa (0.58, p < 0.001). The agreements between previous diagnosis of depression and the diagnoses of the BDI-II/BDI-FS were also significantly higher than chance level (BDI-II: 0.34, p = 0.007, BDI-FS: 0.39, p = 0.002). Additional AUC analysis across different cutoffs showed that performance of BDI-FS was better than BDI-II, supporting the observation of an equivalent or better performance of BDI-FS than BDI-II. Importantly, AUC analysis confirmed that a cutoff = 4 for BDI-FS was suitable in the considered sample of patients with PD-MCI. Discussion: In a cohort of PD-MCI, the BDI-FS demonstrates adequate psychometric properties in comparison to the BDI-II and can be used as a screening measure for assessing depression in cognitively impaired PD patients, focusing solely on psychological symptoms. Still, further research is needed to validate this instrument.

Measurement of the adult human midbrain with transcranial ultrasound.

BACKGROUND: Transcranial sonography is increasingly used to aid clinical diagnoses of movement disorders, for example, to identify an enlarged area of substantia nigra echogenicity in patients with Parkinson's disease. OBJECTIVE: The current study investigated characteristics of the midbrain at the anatomical plane for quantification of substantia nigra echogenicity. METHODS: Area of substantia nigra echogenicity, cross-sectional area of the midbrain, and interpeduncular angle were quantified in two groups of adults aged 18-50 years: 47 healthy non-drug-using controls (control group) and 22 individuals with a history of methamphetamine use (methamphetamine group), a cohort with a high prevalence of enlarged substantia nigra echogenicity and thus risk of Parkinson's disease. RESULTS: In the control group, cross-sectional area of the midbrain (4.47±0.44 cm2) and interpeduncular angle were unaffected by age, sex, or image acquisition side. In the methamphetamine group, cross-sectional midbrain area (4.72±0.60 cm2) and area of substantia nigra echogenicity were enlarged compared to the control group, and the enlargement was sex-dependent (larger in males than females). Whole midbrain area and interpeduncular angle were found to be weak predictors of area of substantia nigra echogenicity after accounting for group and sex. CONCLUSIONS: History of methamphetamine use is associated with an enlarged midbrain and area of substantia nigra echogenicity, and the abnormality is more pronounced in males than females. Thus, males may be more susceptible to methamphetamine-induced changes to the brainstem, and risk of Parkinson's disease, than females.

Electroencephalogram abnormalities in patients with NREM parasomnias.

OBJECTIVE: Electroencephalographic (EEG) changes in patients with NREM parasomnias (NRP) occur in sleep architecture as changes in slow wave sleep or cyclic pattern, which are not considered abnormal. However, abnormalities in EEG in these patients have recently been reported, indicating that EEG patterns in NRPs are not definitive. Moreover, most of the polysomnography (PSG) findings in NRP patients were reported in the adult population requiring data from pediatric population to avoid bias in conclusion. METHODS: In sum, 39 patients with a NRP were undergone comprehensive assessments including a PSG with additional EEG montages. EEG recordings were evaluated in patients without a history of epilepsy and further compared between pediatric and adult patients. RESULTS: Twenty-three (59%) of the patients were pediatric and 77% were male. The mean age was 18.4 (±13.1) years. Of the patients, 19 (49%) had somnambulism, 13 (33%) had confusional arousal and seven (18%) had sleep terrors. Macrostructure of sleep detected by PSG was normal in all patients. After excluding 11 (28%) patients with a positive history of epilepsy, seven (25%) of 28 showed EEG abnormalities within K-complexes in NREM-II stage, six of whom were pediatric patients compared to only one adult (p < 0.05). CONCLUSION: This study showed that patients with NRP may display EEG abnormalities in NREM-II stage. These abnormalities were more frequent in pediatric patients compared to adults. In NRP patients, utmost care should be taken in EEG evaluations to prevent false diagnosis of epilepsy.

Transcranial Sonography Findings in Alzheimer's Disease: A New Imaging Biomarker.

OBJECTIVE: To validate transcranial sonography (TCS) as a novel imaging tool for the assessment of medial temporal lobe (MTL) atrophy (MTA). MATERIALS AND METHODS: Participants with Alzheimer's disease (AD, n = 30) and age-sex-matched controls (n = 30) underwent TCS and MRI. On TCS, MTL structures (choroidal fissure (CF) and temporal horn (TH)) were measured and combined to create an MTA score in sonography (MTA-S). Furthermore, both THs and the third ventricle were combined to form the ventricle enlargement score in sonography (VES-S). On MRI, the MTL was evaluated by linear measurements, MTA scale and hippocampal volumetry. Validation was performed by comparing imaging methods and the patient group. RESULTS: Intraclass correlations for CF and TH showed substantial intra/inter-rater reliability (> 0.80). TCS and MRI showed strong to moderate correlation regarding TH (right = 0.88, left = 0.89) and CF (right = 0.70, left = 0.47). MTA-S correlated significantly with the hippocampal volume (right = -0.51, left = -0.47), predicted group membership in logistic regression (Exp(B) right = 3.0, left = 2.7), and could separate AD patients from controls (AUC = 0.93). An MTA-S of 6 mm and 10 mm discriminated MRI MTA scores 0-1 (from 2-4) and MTA score 4 (from 0-3) with 100 % specificity, respectively. VES-S also showed a moderate correlation with the hippocampal volume (r = -0.66) and could differentiate AD patients from controls (AUC = 0.93). CONCLUSION: Our results suggest that TCS may be an alternative imaging tool for the assessment of MTL atrophy and ventricular enlargement for patients in whom MRI scanning is not possible. Additionally, TCS offers a practical, patient-friendly and inexpensive option for the screening and follow-up of individuals with AD.

The effect of Subthalamic nucleus deep brain stimulation on verb and noun naming in Turkish-Speaking Parkinson's disease patients.

Parkinson's disease (PD) is associated with an action language deficit. Subthalamic nucleus deep brain stimulation (STN DBS) deteriorates verbal fluency, but may improve verb naming more than nouns in PD. We investigated effects of grammatical class (verb vs noun), action content (action vs non-action) of words and unilateral, bilateral or no stimulation on naming. Nouns were named more accurately and faster by controls and PD participants; however the noun-verb difference was higher for PD participants. Language, executive and visuospatial function deficits in PD accounted for this difference between PD group and controls. Noun-verb difference was accounted by differences in imageability, familiarity and complexity of the stimuli. Non-action words were named more accurately than action words in the overall sample. Stimulation conditions did not have an effect on naming. This study in Turkish-speaking participants show an action language deficit due to underlying cognitive deficits without an STN DBS effect in PD.

Third ventricular width assessed by transcranial ultrasound correlates with cognitive performance in Parkinson's disease.

INTRODUCTION: Cognitive impairment and dementia are common in PD; however, no stable marker of cognitive dysfunction is available. Transcranial sonography can evaluate global and focal brain atrophy and has been widely used in the differential diagnosis of parkinsonism. METHODS: 225 consecutive PD patients were recruited in a two-center cross sectional study and underwent a standardized sonographic protocol assessing the third ventricle's width and substantia nigra hyperechogenicity. All subjects were evaluated with an extensive motor and cognitive battery. RESULTS: 222 PD patients were included and classified as PD with normal cognition (PDNC; n = 130), mild cognitive impairment (PD-MCI; n = 61) and dementia (PDD; n = 31). Ventricular width correlated strongly with cognitive performance in all cognitive domains (p < 0.001) while SN size did not. PDD patients had significantly wider ventricles than PD patients without dementia (p < 0.001) while differences between PD-MCI and PDNC or PDD were less strong (p < 0.05). There were no group differences in SN size. ROC analyses resulted in age-related cut-offs of third ventricular diameter for the prediction of PDD (6.0 and 7.5 mm for subjects < and ≥70 years of age, respectively). These cut-offs significantly differentiated PDD from PDNC (p < 0.001) and from all patients without dementia (PDNC + PD-MCI; p < 0.001). CONCLUSIONS: The third ventricular diameter correlated with cognitive performance in all domains and was able to differentiate PDD patients from those without dementia. Longitudinal studies are warranted to evaluate whether transcranial sonography could identify PD patients at risk for a rapid cognitive decline.

Biomarkers of Parkinson's disease: 20 years later.

Despite intensive effort, biomarker research for the detection of prodromal stage, diagnosis and progression of Parkinson's disease (PD) falls short of expectations. This article reviews the attempts in the last 20 years to find a biomarker, addresses challenges along the biomarker search and suggests the steps that should be taken to overcome these challenges. Although several biomarkers are currently available, none of them is specific enough for diagnosis, prediction of future PD or disease progression. The main reason for the failure finding a strong biomarker seems to be drastic heterogeneity of PD, which exhibits itself in all domains; from the clinic to pathophysiology or genetics. The diversity in patient selection, assessment methods or outcomes in biomarker studies also limit the interpretation and generalizability of the data. In search of a reliable biomarker, consideration of novel approaches encompassing individual demographic, clinical, genetic, epigenetic and environmental differences, employment of strategies enabling marker combinations, designing multicenter studies with compatible assessment methods, integration of data from preclinical domains and utilization of novel technology-based assessments are necessary.