Physiotherapy for freezing of gait in Parkinson's disease: a systematic review and meta-analysis. / Fisioterapia para la congelación de la marcha en la enfermedad de Parkinson: revisión sistemática y metaanálisis.

INTRODUCTION: Freezing of gait (FOG) is one of the most severe symptoms associated with Parkinson's disease (PD). Physiotherapy treatment could be an effective strategy for treating FOG, but no systematic review has been carried out in this regard. AIM: To identify the characteristics, methodological quality, and main outcomes of the studies that have analyzed the effects of physiotherapy interventions in FOG up to date, by performing a systematic review and a meta-analysis. PATIENTS AND METHODS: Four electronic databases were searched in order to find randomized controlled trials that provided information regarding the effects of any kind of physiotherapy treatment on FOG. The methodological quality of the included investigations was assessed by means of the PEDro scale. RESULTS: Twelve studies were identified for inclusion into the qualitative analysis, with four randomized controlled trials included in the final meta-analysis. The quality of the trials was generally good. Those physiotherapy modalities including cues were more effective for treating FOG than traditional physiotherapy approaches. The meta-analysis indicated that physiotherapy interventions had a significantly greater impact on FOG than control comparisons. CONCLUSIONS: Physiotherapy treatment, especially those modalities including visual and auditory cueing, should be prescribed to PD patients with FOG. Future studies including PD patients with cognitive impairment and FOG objective measurement tools are need to complete the existing scientific evidence.

TITLE: Fisioterapia para la congelación de la marcha en la enfermedad de Parkinson: revisión sistemática y metaanálisis.Introducción. La congelación de la marcha (CDM) es uno de los síntomas más graves asociados con la enfermedad de Parkinson (EP). El tratamiento fisioterapéutico podría ser una estrategia efectiva para su tratamiento, pero no se ha realizado ninguna revisión sistemática al respecto. Objetivo. Identificar las características, la calidad metodológica y los principales resultados de los estudios que han analizado los efectos de las intervenciones fisioterapéuticas en CDM hasta la fecha, mediante la realización de una revisión sistemática y un metaanálisis. Pacientes y métodos. Se realizaron búsquedas en cuatro bases de datos electrónicas para encontrar ensayos controlados aleatorizados que proporcionaran información con respecto a los efectos de cualquier tipo de tratamiento fisioterapéutico sobre la CDM. La calidad metodológica de las investigaciones se evaluó mediante la escala PEDro. Resultados. Se identificaron 12 estudios para su inclusión en el análisis cualitativo y cuatro ensayos controlados aleatorizados se incluyeron en el metaanálisis final. La calidad de los ensayos fue generalmente buena. Las modalidades de fisioterapia que incluían señales fueron más efectivas para tratar la CDM que los enfoques de fisioterapia tradicionales. El meta­análisis indicó que las intervenciones fisioterapéuticas tuvieron un impacto significativamente mayor sobre la CDM que las comparaciones de control. Conclusiones. El tratamiento fisioterapéutico, especialmente las modalidades que incluyen señales visuales y auditivas, debe prescribirse a los pacientes con EP con CDM. Se necesitan estudios futuros que incluyan pacientes con EP con deterioro cognitivo y herramientas de medición objetiva de la CDM para completar la evidencia científica existente.

[Electrolyte disturbances in geriatric patients with focus on hyponatremia]. / Elektrolytveränderungen im Alter mit Fokus auf Hyponatriämie.

Disturbances of water and electrolyte balance are commonly encountered in older patients due to a multitude of physiological changes and preexisting morbidities with hyponatremia being the most common disorder. Even mild chronic hyponatremia can lead to cognitive deficits and gait instability and is associated with an increased rate of falls and fractures. Additionally, experimental and epidemiological data suggest that hyponatremia promotes bone resorption and therefore increases the risk of osteoporosis. Furthermore, osteoporosis and sarcopenia can be stimulated by hypomagnesemia. Hypernatremia often only results in unspecific symptoms but the condition is associated with a clearly increased mortality. As electrolyte disturbances have a high prevalence in the geriatric population and can contribute to geriatric syndromes and frailty, relevant electrolyte alterations should be excluded in all geriatric patients, in particular after a change in medication schedules.

Osteocondroma de rodilla en un triatleta aficionado / Knee osteochondroma in an amateur triathlete

Introducción: El estudio describe correlaciones clínicas radiológicas después de la observación de la imagen de un Osteocondroma con localización rara en la región posterior de la rodilla, en un triatleta aficionado. Objetivos: Presentar el caso clínico atípico de dolor en la rodilla, y demostrar la aplicabilidad de los exámenes complementarios en la práctica clínica osteopática. Resultados: El triatleta aficionado sufrió la influencia del entrenamiento y de factores intrínsecos de la biomecánica, acarreando lesiones por sobrecarga, visualizadas en los exámenes de imagen y correlacionadas en el análisis de la marcha y las pruebas físicas. Conclusiones: El análisis de la marcha y el razonamiento clínico y radiológico deberían aplicarse para la interpretación del origen de los síntomas y en la decisión de la Terapia Manipulativa Osteopática (AU)

Introduction: The study describes clinical radiological correlations after observation of the image of an Osteochondroma with uncommon localization in the posterior region of the knee in an amateur triathlete. Objectives: Present the atypical clinical case of pain in the knee, and demonstrate the applicability of the supplementary exams in clinical osteopathic practice. Results: The amateur triathlete suffered the influence of training and intrinsic biomechanical factors, involving injuries due to strain, displayed in the imaging tests and correlated in walking tests and physical examinations. Conclusions: Walking tests and clinical and radiological analysis should be applied in order to interpret the origin of the symptoms and the Osteopathic Manipulative Therapy decision (AU)

Non-invasive serial casting to treat idiopathic toe walking in an 18-month old child.

BACKGROUND: Idiopathic toe walking is characterized by persistent toe walking in the absence of clinically diagnosed neuromuscular disease. Treatment options in children diagnosed with idiopathic toe walking include: observation, physical therapy, serial casting, or Achilles tendon (heel cord) lengthening surgery. OBJECTIVE: In this case report, we present a non-invasive serial casting protocol to treat severe and persistent toe walking in an 18-month old child, diagnosed as an idiopathic toe walker following neurological examination. METHODS: A series of below knee casts was used to provide a consistent stretch to the plantar flexor muscles. Upon removal of each set of casts, passive range of motion at the ankles was measured with a goniometer. RESULTS: Four sets of casts, each lasting approximately one week, increased passive ankle dorsiflexion to 10° of neutral and established a heel-toe walking gait. Improvements in ankle range of motion and gait were maintained upon repeated examinations at 3, 7, and 12 months post-casting. CONCLUSIONS: These results demonstrate that non-invasive procedures, such as serial casting, can be successful in very young children diagnosed as idiopathic toe walkers. Early identification and intervention for this diagnosis may eliminate the need for invasive surgeries and associated risks in this population.

High beta activity in the subthalamic nucleus and freezing of gait in Parkinson's disease.

OBJECTIVE: Oscillatory activity in the beta band is increased in the subthalamic nucleus (STN) of Parkinson's disease (PD) patients. Rigidity and bradykinesia are associated with the low-beta component (13-20Hz) but the neurophysiological correlate of freezing of gait in PD has not been ascertained. METHODS: We evaluated the power and coherence of the low- and high-beta bands in the STN and cortex (EEG) of PD patients with (p-FOG) (n=14) or without freezing of gait (n-FOG) (n=8) in whom electrodes for chronic stimulation in the STN had been implanted for treatment with deep brain stimulation. RESULTS: p-FOG patients showed higher power in the high-beta band (F=11.6, p=0.002) that was significantly reduced after l-dopa administration along with suppression of FOG (F=4.6, p=0.042). High-beta cortico-STN coherence was maximal for midline cortical EEG electrodes, whereas the low-beta band was maximal for lateral electrodes (χ(2)=20.60, p<0.0001). CONCLUSIONS: The association between freezing of gait, high-beta STN oscillations and cortico-STN coherence suggests that this oscillatory activity might interfere in the frontal cortex-basal ganglia networks, thereby participating in the pathophysiology of FOG in PD.

Idiopathic toe walking: to treat or not to treat, that is the question.

The natural history and optimal treatment for idiopathic toe walking are unknown. The literature is full of poorly documented treatment regimens with few even medium term follow up studies. The senior author reports his nearly 30 year approach to this disorder and his failed attempt to perform a follow up study of his particular treatment regimen. We conclude with our considered interpretation of the present state of knowledge about idiopathic toe walking and our treatment opinions.

Gait and balance disorders in older adults.

Gait and balance disorders are common in older adults and are a major cause of falls in this population. They are associated with increased morbidity and mortality, as well as reduced level of function. Common causes include arthritis and orthostatic hypotension; however, most gait and balance disorders involve multiple contributing factors. Most changes in gait are related to underlying medical conditions and should not be considered an inevitable consequence of aging. Physicians caring for older patients should ask at least annually about falls, and should ask about or examine for difficulties with gait and balance at least once. For older adults who report a fall, physicians should ask about difficulties with gait and balance, and should observe for any gait or balance dysfunctions. The Timed Up and Go test is a fast and reliable diagnostic tool. Persons who have difficulty or demonstrate unsteadiness performing the Timed Up and Go test require further assessment, usually with a physical therapist, to help elucidate gait impairments and related functional limitations. The most effective strategy for falls prevention involves a multifactorial evaluation followed by targeted interventions for identified contributing factors. Evidence on the effectiveness of interventions for gait and balance disorders is limited because of the lack of standardized outcome measures determining gait and balance abilities. However, effective options for patients with gait and balance disorders include exercise and physical therapy.

Intrafamilial variability in fragile X-associated tremor/ataxia syndrome.

Fragile X-associated tremor/ataxia syndrome (FXTAS) is a progressive adult-onset tremor/ataxia syndrome caused by premutations in the FMR1 gene. In cranial MRI, the most characteristic findings are bilateral T2 hyperintense lesions within the middle cerebellar peduncles. Here we present a sibpair of two affected brothers presenting with very different symptoms (typical FXTAS versus essential tremor-like), disease progression, and MRI findings, illustrating broad intrafamilial variability of FXTAS. Also, their family history suggests further evidence of possible manifestation of FXTAS in women.

Apraxia of lid opening is alleviated by pallidal stimulation in a patient with Parkinson's disease.

Apraxia of lid opening (ALO) is a syndrome characterized by a non-paralytic inability to open the eyes at will in the absence of visible contraction of the orbicularis oculi muscle. Here we report that globus pallidus internus deep brain stimulation on the right side markedly alleviates ALO as well as gait freezing in a patient with Parkinson's disease.