Movement Disorders Clinical Practice最新文献

Background: There is widespread interest in complementary and integrative medicine (CIM) among people with Tourette's syndrome (TS).

Objective: To perform a systematic review of evidence on the use of CIM to reduce tics and improve tic-related quality of life.

Methods: We included clinical studies of CIM in children, adolescents and adults with TS and chronic tic disorders, and assessed the change in tic severity and/or tic-related quality of life using validated scales. Risk of bias of randomized controlled trials was assessed using the risk of bias tool of the American Academy of Neurology, which classifies studies into Class I, II, III or IV based on quality criteria.

Results: 49 clinical studies and three systematic reviews were included. Most studies were rated Class IV and therefore at high risk of bias. Class I studies demonstrated efficacy of functional MRI neurofeedback, 5-Ling granule, Jingxin Zhidong formula, and Ningdong granule in reducing tic severity. Class II studies suggest efficacy of mindfulness-based intervention for tics, acupuncture combined with atlantoaxial joint bone setting therapy, and art therapy. Systematic reviews summarizing the Chinese literature on acupuncture, acupuncture with herbal medicine and massage therapy suggest greater reduction in tics compared to conventional treatments but there is low confidence in the evidence due to poor methodological quality of included studies.

Conclusions: Evidence to support the use of complementary and integrative medicine for TS is limited in methodological quality and widespread applicability. These limitations prohibit evidence-based recommendations for general use among individuals with TS.

Background: Parkinson's disease (PD) is a neurodegenerative disorder associated with motor and nonmotor symptoms.

Objectives: This study assesses levodopa dose management, the therapeutic goals of clinicians, the factors that influence clinicians' choice of therapy, and the role of nonmotor symptoms using real-world evidence from Germany, Italy, and Spain.

Methods: To assess the management of unstable PD patients on levodopa-containing regimens, neurologists were asked to complete questionnaires (n = 181) and prospective electronic patient records (EPR) were collected (n = 2687). Neurologists were asked questions about their practice and approach to unstable PD patients. EPRs were completed by neurologists after each visit with patients, and the objectives of any changes to therapy were recorded.

Results: Seventy-four percent of neurologists cited "improving motor symptoms" as the main objective for increasing daily levodopa dose. This was also the main objective when starting an add-on (50%) and the main reason for selecting a new add-on therapy (29%). In comparison, reducing nonmotor symptoms, depression, and pain was rarely cited as either the main or secondary objective for a therapy selection (15%, 9%, and 9%, respectively) even when over 60% of unstable patients had pain or depression and 29% had both. When the importance of add-on therapy features was rated, "improve quality of life (QoL)" had the highest average score. Improving nonmotor symptoms, pain, and depression was among the lowest-rated therapy feature.

Conclusions: These findings suggest that improving motor symptoms is a key driver of therapeutic choice. In prioritizing motor symptoms, neurologists may unintentionally neglect nonmotor symptoms, despite most patients suffering from pain or depression.

Background: The progression of brain damage in CANVAS/RFC1 remains unclear.

Objective: To describe longitudinal brain changes in CANVAS/RFC1.

Methods: Ten RFC1-positive patients and 10 controls underwent 3T-MRI scans 2 years apart. We analyzed cerebral gray and white matter using FreeSurfer and DTI multiatlas, the cerebellum with CerebNet, and the spinal cord with Spinal Cord Toolbox, respectively. Ataxia severity was measured with SARA. Longitudinal changes were assessed using mixed-effect models and Standardized Response Mean (SRM).

Results: CANVAS/RFC1 patients (mean disease duration: 8.5 ± 3.7 years) showed progressive atrophy in the brainstem (SRM:-3.5), left hippocampus (SRM:-2.1), right thalamus (SRM:-2.6), left cerebellar lobules VI (SRM:-1.1) and X (SRM:-0.7), and reduced spinal cord area at C1 and C2 (SRM:-0.7 each). SARA variation showed lower sensitivity (SRM:0.7).

Conclusions: Patients with CANVAS/RFC1 showed progressive, asymmetrical volume reduction of structures in the brain and spinal cord (C1 and C2), over a period of 2 years, using 3-tesla MRI.

Background: Continuous subcutaneous foslevodopa/foscarbidopa (CSFLI) is emerging as a new treatment for advanced Parkinson's disease (APD), but its efficacy and safety as a second-line infusion therapy in patients previously treated with apomorphine remain to be clarified.

Objectives: The aim of this study was to evaluate the short-term clinical impact of switching from continuous subcutaneous apomorphine infusion (CSAI) to CSFLI in a real-world cohort.

Methods: We conducted a retrospective observational study including 14 patients with APD who transitioned from CSAI to CSFLI. Clinical assessments were performed at baseline (M0) and 3 months after the switch (M3).

Results: At M3, motor complications (Movement Disorder Society-the Unified Parkinson's Disease Rating Scale [MDS-UPDRS Part IV]) were significantly reduced, with improvements in functional scores (Part II), quality of life (Parkinson's Disease Questionnaire-8 [PDQ-8]), clinical global impression of severity (CGI-S), and neuropsychiatric inventory (NPI). No patient discontinued treatment. Two patients developed de novo apathy.

Conclusion: Switching from CSAI to CSFLI is feasible, effective, and well tolerated. Behavioral changes observed in two cases underline the need for clinical awareness when treating patients with subtle cognitive vulnerability.

Background: Functional motor disorder (FMD) is a diagnosis of inclusion based on the presence of positive signs on clinical examination, and only a few tests are validated as biomarkers for FMD identification.

Objectives: The aim of this study was to assess the relative frequency of different types of conventional instrumental investigations (such as magnetic resonance imaging/computed tomography [MRI/CT] scan, dopamine transporter single-photon emission computed tomography (DaT-SPECT), electroencephalography (EEG), neurophysiological tests, and other tests) in FMD patients before diagnosis and to identify the clinical and demographic features associated with their use.

Methods: Data were obtained from the Italian Registry of Functional Motor Disorders, a multicenter initiative involving patients with a diagnosis of clinically definite FMD. Patients were consecutively enrolled at 25 Italian centers during 2 phases. Data collection initially took place between September 2018 and August 2019, and during phase 2, between January 2020 and December 2022.

Results: Among the 853 patients included during the 2 phases of the registry, we identified 794 patients (93.1%) who underwent 1 or more categories of conventional investigations. Overall, conventional investigations were more likely to be performed in older FMD patients (Odds ratio [OR]: 1.02; P = 0.013). Interestingly, we found that more than one category of investigation was more likely to be performed in FMD patients presenting with weakness (OR: 1.85; P = 0.002) and with additional functional symptoms (OR: 1.54; P = 0.026).

Conclusions: Our findings provide novel insights into the complex diagnostic process of FMD patients. This study highlights the need to identify reliable biomarkers that may help physicians diagnose FMD earlier and carefully select the most appropriate conventional investigations.

Background: A satisfying sexual life is essential for maintaining good quality of life and healthy relationships for all individuals, including those with movement disorders and their partners. However, its significance is often overlooked in neurological clinics.

Methods: We review the literature and draw from our own experience to offer a practical approach for assessing and managing sexual health issues in patients with movement disorders.

Results: We begin by introducing fundamental concepts of sexual medicine, emphasizing models of sexual response that offer useful frameworks for diagnostic classification and management practices. We then address the most common sexual problems and disorders, including sexual dysfunction, sexual pain disorders, sexual compulsivity, and paraphilic behaviors, and their connections to different movement disorders. Next, we discuss assessment approaches that encompass biological, psychological, and social factors related to sexual health, including investigations for structural, vascular, or hormonal causes. Brief assessment questionnaires are also discussed. In addition to specific sexual therapeutic practices and supportive psychotherapy, we cover adjustments to pharmacological treatments related to movement disorders, as well as the use of mechanical devices. We also address the need for individualized management in specific cases, such as for patients undergoing deep brain stimulation surgery.

Conclusion: Neurologists can play a key role in addressing sexual health concerns, considering the impact of both the disorder and its treatments. A comprehensive approach includes assessing biological, psychological, and sociocultural factors, with interventions like sexual therapy, supportive psychotherapy, pharmacological treatments and medical devices. Further research is needed to establish evidence-based treatments in this population.

Background: Parkinson's disease (PD) leads to handwriting abnormalities primarily characterized by micrographia. Whether micrographia manifests early in PD, worsens throughout the disease, and lastly responds to L-Dopa is still under scientific debate.

Objectives: We investigated the onset, progression and L-Dopa responsiveness of micrographia in PD, by applying a non-invasive and cheap tool of artificial intelligence- (AI)-based pen-and-paper handwriting analysis.

Methods: Fifty-seven PD undergoing chronic L-Dopa treatment were enrolled, including 30 early-stage (H&Y ≤ 2) and 27 mid-advanced stage (H&Y > 2) patients, alongside 25 age- and sex-matched controls. Participants completed two standardized pen-and-paper handwriting tasks in an ecological scenario. Handwriting samples were examined through clinically-based (ie, perceptual) and AI-based (ie, automatic) procedures. Both consistent (ie, average stroke size) and progressive (ie, sequential changes in stroke size) micrographia were evaluated. Receiver operating characteristic (ROC) curves were used to evaluate the accuracy of the convolutional neural network (CNN) in classifying handwriting in PD and controls.

Results: Clinically- and AI-based analysis revealed a general reduction in stroke size in PD supporting the concept of parkinsonian micrographia. Compared with perceptual analysis, AI-based analysis clarified that micrographia manifests early during the disease, progressively worsens and poorly responds to L-Dopa. The AI models achieved high accuracy in distinguishing PD patients from controls (91%), and moderate accuracy in differentiating early from mid-advanced PD (77%). Lastly, the AI model was not able to detect patients in OFF and ON states.

Conclusions: AI-based handwriting analysis is a valuable non-invasive and cheap tool for detecting and quantifying micrographia in PD, for telemedicine purposes.