Forehead sympathetic skin responses in determining autonomic involvement in Parkinson’s disease

ObjectiveThe purpose of this study was to evaluate forehead sympathetic skin response (SSR) and demonstrate any differences with extremity SSR in determining autonomic nervous system (ANS) involvement in patients with Parkinson’s disease (PD).MethodsTwenty early stage, 20 advanced stage idiopathic PD patients and 20 healthy controls participated in this study. SSR of forehead, hands and feet, heart rate variability (HRV), orthostatic intolerance, QT intervals and dysautonomic symptoms were evaluated.ResultsAbsent forehead SSR was determined unilaterally in 4, bilaterally in 7 early stage patients, and unilaterally in 4, bilaterally in 8 advanced stage PD patients; there was significant difference between early and advanced stage PD and control groups in terms of the lack of SSR (p = 0.000). Absent extremity SSR was determined in at least 1 extremity of 3 advanced stage PD patients, and none of the early stage PD patients. No difference was noted in HRV at rest between early and advanced stage PD and control groups (p = 0.218); but HRV at deep breathing was lower in both early and advanced PD patients compared to controls (p = 0.014, p = 0.002, respectively).ConclusionForehead SSR is more sensitive in determining ANS dysfunction not only in late but also in early stage of PD.SignificanceWith further supportive research, forehead SSR might be used as a simple diagnostic electrophysiological test in the early diagnosis of ANS dysfunction enabling proper treatment and increasing the quality of life of PD patients.     

Ventricular fibrillation as a primary manifestation of Wolff–Parkinson–White syndrome

Wolff–Parkinson–White syndrome (WPW) is defined as a condition involving an accessory pathway associated with symptoms. A typical ECG pattern of a pre-excitation shows a short PQ interval, presence of delta wave and a broad QRS complex on surface ECG. The underlying mechanism involves an accessory pathway, which enables conduction of a depolarization wave from atria to ventricles bypassing the AV node and predisposes to arrhythmias and sudden cardiac death. The most common arrhythmia in patients with WPW syndrome is atrioventricular reentrant tachycardia. However, it is not present in all patients with pre-excitation [1], [2], [3], [4]. Up to 1/3 of patients with AVRT experience atrial fibrillation, which may be conducted to ventricular myocardium via the accessory pathway and lead to a life-threatening ventricular fibrillation. The most effective treatment of the WPW syndrome is a radiofrequency catheter ablation [2], [5], [6], [7], [8]. This paper describes a case of a 40-year-old woman after a cardiopulmonary resuscitation for ventricular fibrillation, which was a primary manifestation of the WPW syndrome. It focuses on pathophysiology, clinical pattern and treatment possibilities of patients with WPW syndrome.     

Prefrontal D1 dopamine signaling is required for temporal control

Temporal control, or how organisms guide movements in time to achieve behavioral goals, depends on dopamine signaling. The medial prefrontal cortex controls many goal-directed behaviors and receives dopaminergic input primarily from the midbrain ventral tegmental area. However, this system has never been linked with temporal control. Here, we test the hypothesis that dopaminergic projections from the ventral tegmental area to the prefrontal cortex influence temporal control. Rodents were trained to perform a fixed-interval timing task with an interval of 20 s. We report several results: first, that decreasing dopaminergic neurotransmission using virally mediated RNA interference of tyrosine hydroxylase impaired temporal control, and second that pharmacological disruption of prefrontal D1 dopamine receptors, but not D2 dopamine receptors, impaired temporal control. We then used optogenetics to specifically and selectively manipulate prefrontal neurons expressing D1 dopamine receptors during fixed-interval timing performance. Selective inhibition of D1-expressing prefrontal neurons impaired fixed-interval timing, whereas stimulation made animals more efficient during task performance. These data provide evidence that ventral tegmental dopaminergic projections to the prefrontal cortex influence temporal control via D1 receptors. The results identify a critical circuit for temporal control of behavior that could serve as a target for the treatment of dopaminergic diseases.     

Postural motor learning in Parkinson’s disease: The effect of practice on continuous compensatory postural regulation

IntroductionAlthough balance training is considered the most effective treatment for balance impairments in Parkinson’s disease (PD), few studies have examined if learning for balance control remains intact with PD. This study aimed to determine if learning for automatic postural responses is preserved in people with PD.MethodsEleven participants with moderate PD (68 ± 6.4 years; H&Y: 2–3) on their usual medication maintained balance on a platform that oscillated forward and backward with variable amplitude and constant frequency. Participants completed 42 trials during one training session, and retention and transfer tests following a 24-h delay. Performance was measured by comparing spatial and temporal measures of whole-body centre of mass (COM) with platform displacements. Learning was compared between participants with PD and previously reported, age-matched older adults (Van Ooteghem et al., 2010).ResultsAlthough postural responses in participants with PD were impaired compared to control participants, a majority of PD participants improved their postural responses with practice as revealed by reduced COM displacements and improved phase relationships between COM and platform motion. Rates of improvement were comparable between groups demonstrating preserved adaptive capacity for participants with PD. Similar to control participants, the PD group moved toward anticipatory COM control as a strategy for improving stability, exhibited short-term retention of performance improvements, and demonstrated generalizability of the learned responses. Rate of improvement with practice, but not retention, was related to severity of motor impairments.ConclusionsPatients with moderate PD on medication demonstrate retention of improvements in automatic postural responses with practice suggesting that intrinsic postural motor learning is preserved in this group.     

Subthalamic nucleus stimulation and gait in Parkinson’s Disease: a not always fruitful relationship

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) provides efficient treatment for the alleviation of motor signs in patients with advanced Parkinson’s disease (PD), but its specific effects on gait is sometimes less successful as it may even lead to an aggravation of freezing of gait. To better understand when axial symptoms can be expected to improve and when they may worsen or be resistant to STN-DBS, we propose here a narrative review that considers the recent literature evidences based on instrumental gait analysis data. Our aim is to report about the efficacy of STN-DBS on PD gait, analyzing the clinical and procedural factors involved, and discussing the strategies for optimizing such effectiveness in patients with advanced PD.     

A technical concept of a computer game for patients with Parkinson's disease – a new form of PC-based physiotherapy

Background: At present, there are no meaningful and sophisticated computer games that simultaneously allow the treatment of movement disorders such as Parkinson's syndrome. In particular, there are no systems to consider the severity of the disease and the physical skills of the patient.

Methods: A computer game using the Microsoft Kinect as markerless sensor for the 3?D recognition of the patient’s movement was developed to support the rehabilitation. The scenario of a basketball game was created after determining that the movement like throwing a ball and the correct posture of the body are important. A study based on system usability was performed with 15 patients to evaluate the system.

Results: The technical feasibility of a computer-assisted training system for supporting patients with Parkinson‘s disease has been demonstrated. No markers on the patient are required for movement detection and allow a user-friendly handling. Regarding the usability study, the patients were accepting of such a system and its at-home use and symptoms like ‘freezing’ and the Pisa syndrome can be treated.

Conclusions: The physiotherapist can be assisted by the developed rehabilitation system. An objective measurement of the patient’s training progress delivers valuable information to adjust the training sessions for every patient individually. Due to its modular character, the system can also be applied to other diseases or sports injuries and offers the basis for further development.     

Postural instability in Parkinson’s disease: Review and bottom-up rehabilitative approaches

The aims of this narrative review are to provide scientific support to characterize the postural instability commonly observed in Parkinson’s disease (PD), and to emphasize how bottom-up rehabilitation programs stimulating the sole of the foot can improve postural stability in PD. Postural instability is a typical characteristic of individuals with PD, which increases the frequency of falls and may worsen their consequences. It thus seems relevant to diagnose these alterations as early as possible, in order to develop specific rehabilitative treatment. The association between sensitivity of the sole of the foot and postural instability in individuals with PD is linked to the key role of peripheral alterations of the sensorimotor system in balance and motor symptoms. By enhancing sensory feedback coming from the feet, bottom-up stimulation allows patients to improve their sensorimotor control. In clinical practice, health practitioners can use sensory stimulation to improve postural control. By improving postural stability, a decrease in fall risk can be achieved and the secondary impairments associated with falls prevented.     

Effects of handwriting exercise on functional outcome in Parkinson disease: A randomized controlled trial

Parkinson disease (PD) patients frequently experience micrographia and difficulty writing, which could potentially impact their quality of life. This study aimed to determine whether handwriting exercise could improve fine manual motor function in PD. The study was a randomized controlled trial assessing the efficacy of a 4-week handwriting exercise using a newly developed handwriting practice book. The primary endpoint was an improvement in the time used to complete the handwriting test. Secondary endpoints were accuracy of the writing performance, patient’s subjective rating scale of their handwriting and a UPDRS part III motor examination. Of a total of 46 subjects, 23 were randomly assigned to the handwriting exercise group. After 4 weeks, the mean time used to complete the test was significantly lower in the exercise group, compared to the control group (143.43 ± 34.02 vs. 175 ± 48.88 s, p = 0.015). Mean time used to complete the handwriting test decreased from the baseline by 16.16% in the exercise group, but increased by 3.63% in the control group (p < 0.001). Significant improvements were also observed by assessing the subjective rating scale and the UPDRS part III scores. The 4-week handwriting exercise using the studied handwriting practice book appears to promote an improvement in writing speed and motor function of hands. The optimal duration and frequency of the exercise, the quantity and characteristic of the letters in the handwriting practice book, and the benefits of the exercise in other languages merit further studies.     

The presence of a caregiver is associated with patient outcomes in patients with Parkinson's disease and atypical parkinsonisms

IntroductionApproximately 88% of men and 79% of women with Parkinson's disease (PD) identify an informal caregiver. Although caregivers can play a key role in supporting patients, little is known about how and whether PD patients with and without caregivers differ in terms of physical, cognitive, and mood outcomes. This study explored whether caregiver presence was associated with variations in patient presentation and outcomes in a palliative PD and atypical PD population.MethodsSecondary data on individuals with PD and their caregivers came from baseline data of a 3-site randomized controlled trial of outpatient palliative care for PD in the US and Canada. Measures included: MDS UPDRS III, Montreal Cognitive Assessment, quality of life (QOL) measures, depression, prolonged grief, spirituality (FACIT SP-12) and Palliative Performance Scale.ResultsOf 210 participants, 175 (83%) had a caregiver. Patients with caregivers had greater motor difficulty, lower cognitive scores, and greater palliative needs as measured by the Palliative Performance Scale. Despite poorer cognitive and motor function, those with caregivers had higher QOL as measured by the Quality of Life in Alzheimer Disease and less spiritual distress. There were no group differences on anxiety, depression, or grief. Caregiver presence moderated the association between lower MoCA score and worse motor symptoms.ConclusionFindings of the present study highlight the influence of caregiver engagement on PD patient outcomes. These findings have implications for clinical practice and suggest that presence of a caregiver may be an important modifying variable on patient outcomes to examine in future research.