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

BACKGROUND: The Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) has become the gold standard for evaluating different domains in Parkinson's disease (PD), and it is commonly used in clinical practice, research, and clinical trials. OBJECTIVES: The objectives are to validate the Arabic-translated version of the MDS-UPDRS and to assess its factor structure compared with the English version. METHODS: The study was carried out in three phases: first, the English version of the MDS-UPDRS was translated into Arabic and subsequently back-translated into English by independent translation team; second, cognitive pretesting of selected items was performed; third, the Arabic version was tested in over 400 native Arabic-speaking PD patients. The psychometric properties of the translated version were analyzed using confirmatory factor analysis (CFA) as well as exploratory factor analysis (EFA). RESULTS: The factor structure of the Arabic version was consistent with that of the English version based on the high CFIs for all four parts of the MDS-UPDRS in the CFA (CFI ≥0.90), confirming its suitability for use in Arabic. CONCLUSIONS: The Arabic version of the MDS-UPDRS has good construct validity in Arabic-speaking patients with PD and has been thereby designated as an official MDS-UPDRS version. The data collection methodology among Arabic-speaking countries across two continents of Asia and Africa provides a roadmap for validating additional MDS rating scale initiatives and is strong evidence that underserved regions can be energically mobilized to promote efforts that apply to better clinical care, education, and research for PD. © 2022 International Parkinson and Movement Disorder Society.

Use of Twitter in Neurology: Boon or Bane?

Twitter is a free, open access social media platform that is widely used in medicine by physicians, scientists, and patients. It provides an opportunity for advocacy, education, and collaboration. However, it is likely not utilized to its full advantage by many disciplines in medicine, and pitfalls exist in its use. In particular, there has not been a review of Twitter use and its applications in the field of neurology. This review seeks to provide an understanding of the current use of Twitter in the field of neurology to assist neurologists in engaging with this potentially powerful application to support their work.

Individual Magnetoencephalography Response Profiles to Short-Duration L-Dopa in Parkinson's Disease.

Clinical responses to dopamine replacement therapy for individuals with Parkinson's disease (PD) are often difficult to predict. We characterized changes in MDS-UPDRS motor factor scores resulting from a short-duration L-Dopa response (SDR), and investigated how the inter-subject clinical differences could be predicted from motor cortical magnetoencephalography (MEG). MDS-UPDRS motor factor scores and resting-state MEG recordings were collected during SDR from twenty individuals with a PD diagnosis. We used a novel subject-specific strategy based on linear support vector machines to quantify motor cortical oscillatory frequency profiles that best predicted medication state. Motor cortical profiles differed substantially across individuals and showed consistency across multiple data folds. There was a linear relationship between classification accuracy and SDR of lower limb bradykinesia, although this relationship did not persist after multiple comparison correction, suggesting that combinations of spectral power features alone are insufficient to predict clinical state. Factor score analysis of therapeutic response and novel subject-specific machine learning approaches based on subject-specific neuroimaging provide tools to predict outcomes of therapies for PD.

Neuromodulation Options and Patient Selection for Parkinson's Disease.

Neuromodulation therapies, including deep brain stimulation (DBS) and pump therapies, are currently the standard of care for PD patients with advanced disease and motor complications that are difficult to control with medical management alone. The quest for alternate lesser invasive approaches led to the development of several novel therapies like intrajejunal levodopa infusions (IJLI), continuous subcutaneous apomorphine infusions (CSAI) and Magnetic Resonance guided Focused Ultrasound (MRgFUS) in recent years. To achieve good outcomes with any of these therapeutic modalities, careful patient selection, multidisciplinary evaluation and technical expertise are equally important. In this review, we will provide an overview of the neuromodulation strategies currently available for PD, emphasizing on patient selection and choosing among the various strategies.

Global Survey on Telemedicine Utilization for Movement Disorders During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic restricted usual healthcare management for movement-disorders patients, with a consequent upsurge in telemedicine to bridge the gap. OBJECTIVE: To assess global telemedicine usage in the context of the pandemic. METHODS: The Movement Disorder Society (MDS) Telemedicine Study Group surveyed telemedicine experts from 40 countries across all continents in March-April 2020. Four domains of telemedicine were assessed: legal regulations, reimbursement, clinical use, and barriers; comparing emerging responses to the pandemic versus the baseline scenario. RESULTS: All forms of telemedicine for movement disorders increased globally, irrespective of country income categorization, as an immediate response to the pandemic. This was aided by widespread availability of technology and updated government regulations. However, privacy concerns, lack of reimbursement, limited access, and lack of telemedicine training were barriers highlighted worldwide. CONCLUSIONS: Questions remain about the longevity and extent of changes in regulations and reimbursement regarding telemedicine in the aftermath of the pandemic. © 2020 International Parkinson and Movement Disorder Society.

Parkinson's Disease in the Middle East, North Africa, and South Asia: Consensus from the International Parkinson and Movement Disorder Society Task Force for the Middle East.

BACKGROUND: Understanding the regional needs and available healthcare resources to treat Parkinson's disease (PD) is essential to plan appropriate future priorities. The International Parkinson and Movement Disorder Society (MDS) Task Force for the Middle East was established to raise awareness and promote education across the region on PD and other movement disorders. Broadly, the task force encompasses the countries of the Middle East but has included North Africa and South Asia as well (MENASA). OBJECTIVE: To create a list of needs and priorities in the advancement of PD in MENASA countries based on consensuses generated by the MDS task force for the Middle East. METHODS: A Strengths Weaknesses-Opportunities-Threats (SWOT) analysis was conducted by the task force members to generate consensus about PD care this region. RESULTS: Eight overarching principles emerged for the consensus statement on current needs: more movement disorders specialists, multidisciplinary care, accurate epidemiologic data, educational programs, availability of drugs, and availability of more advanced therapy, enhanced health care resources and infrastructure, and greater levels of awareness within the general population and among health care professionals. CONCLUSION: This pilot study sheds light on unmet needs for providing care to people with PD in the MENASA region. These data offer directions on priorities to increase awareness of PD, to develop better infrastructure for research and management of PD, to foster healthcare policy discussions for PD and to provide educational opportunities within these countries.

Rationale and patient selection for interventional therapies in Parkinson's disease.

INTRODUCTION: Parkinson's disease (PD) is increasing in prevalence due to a growing elderly population. Although there is no cure, there are exercise therapies and medications for mild to moderate disease. For more advanced disease, infusion or surgical interventions including deep brain stimulation surgery, levodopa carbidopa intestinal gel, and subcutaneous apomorphine infusion are considered. As these interventions become increasingly available, it is imperative for a neurologist involved in the care of advanced PD to be aware of the indications and timing for these interventions. Areas covered: This article attempts to identify different patient profiles and matches them with suggested advanced therapies for PD. There is limited literature providing guidance to a busy neurologist to match the most appropriate advanced therapy to the right patient profile. This article attempts to fill that void. Expert commentary: When matching patient profiles to therapy, several features must be considered: age, frailty, cognitive status, phenotype (predominant tremor vs. akinetic rigid), side effect or complication profile (dyskinesia, hallucinations, dysautonomia), and patient's comfort with invasive therapy options.

Telemedicine Use for Movement Disorders: A Global Survey.

BACKGROUND: Telemedicine is increasingly used to care for patients with movement disorders, but data regarding its global use are limited. INTRODUCTION: To obtain baseline international data about telemedicine use among movement disorder clinicians. METHODS: An online survey was sent to all 6,056 Movement Disorder Society members in 2015. Scope, reimbursement, and perceived quality of telemedicine were assessed. RESULTS: There were 549 respondents (9.1% overall response rate) from 83 countries. Most (85.8%) were physicians, and most (70.9%) worked in an academic or university practice. Half of respondents (n = 287, from 57 countries) used telemedicine for clinical care; activities included e-mail (63.2%), video visits (follow-up [39.7%] and new [35.2%]), and video-based education (35.2%). One hundred five respondents personally conducted video visits, most frequently to outpatient clinics (53.5%), patient homes (30.8%), and hospital inpatients (30.3%). The most common challenges were a limited neurological examination (58.9%) and technological difficulties (53.3%), and the most common benefits were reduced travel time (92.9%) and patient costs (60.1%). The most frequent reimbursements were none (39.0%), public insurance (24.5%), and patient payment (9.3%). Half of respondents planned to use telemedicine in the future, and three-quarters were interested in telemedicine education. CONCLUSIONS: More than 250 respondents around the world engage in telemedicine for movement disorders; most perceived benefit for patients, despite challenges and reimbursement for clinicians. Formal instruction on telemedicine is highly desired. Although the survey response was low and possibly biased to over represent those with telemedicine experience, the study provides baseline data for future comparison and to improve telemedicine delivery.

Movement Disorders and Deep Brain Stimulation in the Middle East.

BACKGROUND: Deep brain stimulation (DBS) is a well-established neuromodulation therapy for advanced Parkinson disease, essential tremor and dystonia. In as much as this therapy is being developed in the Middle East, a better understanding of the incidence and prevalence of movement disorders, health care, and social framework is required for the region. METHODS: We reviewed current literature on the incidence and prevalence of various movement disorders in the Middle East amenable to DBS surgery. We also assessed recent efforts to develop DBS in the region. RESULTS: Available data on incidence and prevalence of movement disorders in the Middle East are old, inconclusive, and conflicting. We identify key areas such as cultural background, availability of accessible information, training, infrastructure, and public support groups in the region that may pose challenges. CONCLUSIONS: The Middle East is projected to be a growing market for neuromodulation. The available data on incidence and prevalence of movement disorders is from studies that were small, partial, and old, with inconsistent results, highlighting the need for newer, better-designed, and larger studies. DBS in the Middle East will need assessment of incidence and prevalence of movement disorders, existing challenges to its application, and focused efforts on key opportunities to foster development of DBS for this underserved region. This article is an attempt to identify and explore these challenges and propose solutions in anticipation.

DBS Programming: An Evolving Approach for Patients with Parkinson's Disease.

Deep brain stimulation (DBS) surgery is a well-established therapy for control of motor symptoms in Parkinson's disease. Despite an appropriate targeting and an accurate placement of DBS lead, a thorough and efficient programming is critical for a successful clinical outcome. DBS programming is a time consuming and laborious manual process. The current approach involves use of general guidelines involving determination of the lead type, electrode configuration, impedance check, and battery check. However there are no validated and well-established programming protocols. In this review, we will discuss the current practice and the recent advances in DBS programming including the use of interleaving, fractionated current, directional steering of current, and the use of novel DBS pulses. These technological improvements are focused on achieving a more efficient control of clinical symptoms with the least possible side effects. Other promising advances include the introduction of computer guided programming which will likely impact the efficiency of programming for the clinicians and the possibility of remote Internet based programming which will improve access to DBS care for the patients.

The Association Between Physical Activity With Cognitive Function and Brain-Derived Neurotrophic Factor in People With Parkinson's Disease: A Pilot Study.

The objective of this study was to examine the effect of physical capacity on the relationship of brain-derived neurotrophic factor (BDNF) with cognitive function in people with PD. For this study, serum BDNF levels were measured in 29 PD participants and 30 healthy controls. Cognitive function was assessed using the Montreal Cognitive Assessment (MOCA) scale. Physical capacity was evaluated using the 6-min walk distance (6-MWD). Participants were categorized into low or high physical capacity group according to their 50th percentile 6-MWD. It was found that MOCA total score correlated with serum BDNF level (r = .44, P = .012) in the entire PD sample. This correlation remained significant only in the low physical capacity group (r = .62; P = .03) but not in the high physical capacity group (r = .31; P = .22). It was concluded that the relationship of BDNF with cognitive function might be dependent on physical capacity. The results are preliminary, thus future studies are needed to confirm these findings.

Cognitive Impact of Deep Brain Stimulation on Parkinson's Disease Patients.

Subthalamic nucleus (STN) or globus pallidus interna (GPi) deep brain stimulation (DBS) is considered a robust therapeutic tool in the treatment of Parkinson's disease (PD) patients, although it has been reported to potentially cause cognitive decline in some cases. We here provide an in-depth and critical review of the current literature regarding cognition after DBS in PD, summarizing the available data on the impact of STN and GPi DBS as monotherapies and also comparative data across these two therapies on 7 cognitive domains. We provide evidence that, in appropriately screened PD patients, worsening of one or more cognitive functions is rare and subtle after DBS, without negative impact on quality of life, and that there is very little data supporting that STN DBS has a worse cognitive outcome than GPi DBS.

Relationship of circulatory BDNF with cognitive deficits in people with Parkinson's disease.

BACKGROUND: Brain-derived neurotrophic factor (BDNF) and cognitive function are diminished in people with Parkinson's disease (PD). The relationship of cognitive function and serum level of BDNF, however is yet to be examined. The aim of this study was to examine serum BDNF levels in PD. Subsequently, the relationship of cognitive function to the serum levels of BDNF was evaluated. METHODS: Serum BDNF levels were measured in 29 idiopathic PD subjects and 30 healthy-matched controls using ELISA technique. Cognitive function was assessed using the Montreal Cognitive Assessment (MOCA) scale. RESULTS: Serum BDNF levels and MOCA total score were significantly lower (P<0.001) in PD patients versus healthy controls. MOCA total score correlated with serum BDNF (r=0.44; P=0.012) but not with age, years of education, duration of disease and severity of symptoms. The regression analysis showed that serum BDNF accounted (P=0.019) for 19% of MOCA total score variance. CONCLUSIONS: The data confirm lowered serum BDNF in PD. Additionally; it suggests that BDNF may play a role in the cognitive deficit of PD. Further studies are required to identify association of BDNF in cognitive decline with PD.

Asian perspectives on the recognition and management of levodopa 'wearing-off' in Parkinson's disease.

Most Parkinson's disease patients will receive levodopa therapy, and of these, the majority will develop some levodopa-induced complications. For many patients, the first complication to develop is the decline in the duration of therapeutic benefit of each levodopa dose, a phenomenon commonly termed 'wearing-off'. There is already extensive literature documenting the epidemiology and management of wearing-off in Parkinson's disease patients of western descent. However, data derived from these studies might not always apply to patients of Asian descent due to genetic variations, differences in co-morbidities or non-availability of certain drugs. This review summarizes the current literature regarding the epidemiology of wearing-off in Asian (including Arab) patients and discusses the management issues in the context of drug availability in Asia.

Computational modeling of an endovascular approach to deep brain stimulation.

OBJECTIVE: Deep brain stimulation (DBS) therapy currently relies on a transcranial neurosurgical technique to implant one or more electrode leads into the brain parenchyma. In this study, we used computational modeling to investigate the feasibility of using an endovascular approach to target DBS therapy. APPROACH: Image-based anatomical reconstructions of the human brain and vasculature were used to identify 17 established and hypothesized anatomical targets of DBS, of which five were found adjacent to a vein or artery with intraluminal diameter ≥1 mm. Two of these targets, the fornix and subgenual cingulate white matter (SgCwm) tracts, were further investigated using a computational modeling framework that combined segmented volumes of the vascularized brain, finite element models of the tissue voltage during DBS, and multi-compartment axon models to predict the direct electrophysiological effects of endovascular DBS. MAIN RESULTS: The models showed that: (1) a ring-electrode conforming to the vessel wall was more efficient at neural activation than a guidewire design, (2) increasing the length of a ring-electrode had minimal effect on neural activation thresholds, (3) large variability in neural activation occurred with suboptimal placement of a ring-electrode along the targeted vessel, and (4) activation thresholds for the fornix and SgCwm tracts were comparable for endovascular and stereotactic DBS, though endovascular DBS was able to produce significantly larger contralateral activation for a unilateral implantation. SIGNIFICANCE: Together, these results suggest that endovascular DBS can serve as a complementary approach to stereotactic DBS in select cases.

Improved spatial targeting with directionally segmented deep brain stimulation leads for treating essential tremor.

Deep brain stimulation (DBS) in the ventral intermediate nucleus of thalamus (Vim) is known to exert a therapeutic effect on postural and kinetic tremor in patients with essential tremor (ET). For DBS leads implanted near the caudal border of Vim, however, there is an increased likelihood that one will also induce paresthesia side-effects by stimulating neurons within the sensory pathway of the ventral caudal (Vc) nucleus of thalamus. The aim of this computational study was to (1) investigate the neuronal pathways modulated by therapeutic, sub-therapeutic and paresthesia-inducing DBS settings in three patients with ET and (2) determine how much better an outcome could have been achieved had these patients been implanted with a DBS lead containing directionally segmented electrodes (dDBS). Multi-compartment neuron models of the thalamocortical, cerebellothalamic and medial lemniscal pathways were first simulated in the context of patient-specific anatomies, lead placements and programming parameters from three ET patients who had been implanted with Medtronic 3389 DBS leads. The models showed that in these patients, complete suppression of tremor was associated most closely with activating an average of 62% of the cerebellothalamic afferent input into Vim (n = 10), while persistent paresthesias were associated with activating 35% of the medial lemniscal tract input into Vc thalamus (n = 12). The dDBS lead design demonstrated superior targeting of the cerebello-thalamo-cortical pathway, especially in cases of misaligned DBS leads. Given the close proximity of Vim to Vc thalamus, the models suggest that dDBS will enable clinicians to more effectively sculpt current through and around thalamus in order to achieve a more consistent therapeutic effect without inducing side-effects.

Cortical magnetoencephalography of deep brain stimulation for the treatment of postural tremor.

The effects of deep brain stimulation (DBS) on motor cortex circuitry in Essential tremor (ET) and Parkinson's disease (PD) patients are not well understood, in part, because most imaging modalities have difficulty capturing and localizing motor cortex dynamics on the same temporal scale as motor symptom expression. Here, we report on the use of magnetoencephalography (MEG) to characterize sources of postural tremor activity within the brain of an ET/PD patient and the effects of bilateral subthalamic nucleus DBS on these sources. Recordings were performed during unilateral and bilateral DBS at stimulation amplitudes of 0 V, 1 V, and 3 V corresponding to no therapy, subtherapeutic, and therapeutic configurations, respectively. Dipole source localization in reference to the postural tremor frequency recorded with electromyography (EMG) showed prominent sources in both right and left motor cortices when no therapy was provided. These sources dissipated as the amplitude of stimulation increased to a therapeutic level (P = 0.0062). Coherence peaks between the EMG and MEG recordings were seen at both 4 Hz, postural tremor frequency, and at 8 Hz, twice the tremor frequency, with no therapy. Both peaks were reduced with therapeutic DBS. These results demonstrate the capabilities of MEG to record cortical dynamics of tremor during deep brain stimulation and suggest that MEG could be used to examine DBS in the context of motor symptoms of PD and of ET.