England Activities Of Daily Living Research Articles

Freezing of Gait and Activity Limitations in People With Parkinson's Disease

Tan DM, McGinley JL, Danoudis ME, Iansek R, Morris ME. Freezing of gait and activity limitations in people with Parkinson's disease. Objectives To investigate the relationships between freezing of gait (FOG) and activity limitations in ambulant people with Parkinson's disease (PD), and to explore the contribution of FOG and gait hypokinesia to activity limitations after adjusting for the effects of disease severity. Design Retrospective, cross-sectional design. Setting Participants were recruited from neurologists' clinics and the general public in metropolitan Melbourne, Australia. Participants Volunteers were screened for eligibility using the following inclusion criteria: diagnosis of idiopathic PD, modified Hoehn and Yahr stages 0 to IV, without dementia. Participants (N=210) were tested (mean age ± SD, 67.9±9.6y; mean PD duration ± SD, 6.7±5.6y; median Hoehn and Yahr stage=2.5). Interventions Not applicable. Main Outcome Measures FOG was measured using the FOG questionnaire. Gait hypokinesia was quantified using both the 6-meter walk test and the Timed Up and Go test. Activity limitation was measured using the modified Unified Parkinson's Disease Rating Scale activities of daily living (ADL) section and the Schwab and England ADL scale. Results Severity of gait freezing correlated significantly with the level of activity limitation (Spearman correlation coefficient, ρ=−.49 to .48; P<.001). A hierarchic regression model showed that disease severity explained 37.5% of the variance in Schwab and England ADL score ( P<.001). Gait hypokinesia and FOG severity scores explained an additional 9.1% of the variance in activity limitation ( R 2 change=.091; P<.001). Conclusions FOG severity and gait hypokinesia were associated with reduced levels of activity after adjusting for disease severity.

The development and validation of a new comprehensive self-completing questionnaire for symptoms in Parkinson's disease (MASAC-PD 31)

Patients with Parkinson's disease (PD) suffer from various symptoms. In order to identify untreated symptoms within the limited time of a clinical interview, we developed a new self-completing questionnaire (MASAC-PD 31). The questionnaire consists of two parts (5 domains, 31 items); Part I intended at rating the motor symptoms and activities of daily living (ADL) during both "on" and "off" periods, and Part II aimed at screening and assessing mainly the non-motor symptoms, such as sleep-related difficulties, autonomic symptoms, cognition, mood and others. The purpose of this study was to evaluate the validity, reliability, and clinical usefulness of the questionnaire. Based on the number of valid answers in a pilot trial, MASAC-PD 31 was refined by improving the expression and layout. Of the initially enrolled 107 patients attending three hospitals, 102 patients were included in the final analysis. Correlations of the scores on the MASAC-PD 31 with other clinical scales were evaluated. A second trial consisting of 57 participants was conducted a month later to assess the test-retest reproducibility of the questionnaire. The average time needed to complete MASAC-PD 31 was 17 min (range: 3-90 min). Each of the domains in Part I showed high internal consistency (Cronbach's alpha: 0.663 for "on" motor) and strong correlations with preexisting indices (Spearman's correlation coefficient: 0.547, 0.544, and 0.571 for "on" motor against "on" UPDRS, PDQ-39, and Schwab & England ADL scale, respectively). The questions in the Part II domains also showed strong correlations with preexisting scales. Most of the items showed high reproducibility (weighted kappa coefficient) and consistency. This new comprehensive questionnaire was shown to be valid and reliable for assessing the motor disability in patients with PD. Moreover, it may be useful in clinical management for identifying clinically unrecognized symptoms, especially non-motor problems.

A meta-analysis on transcranial magnetic stimulation for Parkinson's disease

Objective To systematically review findings on the effectiveness and safety of transcranial magnetic stimulation (TMS) for treating Parkinson's disease. Methods Foreign and Chinese databases were searched to find relevant trials. The searches were supplemented by searching the reference lists of the published trials. The studies were separated into two groups: those applying TMS at frequencies higher than 1 Hz, and those at 1 Hz or lower. Meta-analysis was performed with the aid of RevMan 5.0 software. Results Both low-frequency and highfrequency TMS can significantly reduce total scores on the Unified Parkinson's Disease Rating Scale (UPDRS) compared with sham stimulations. High-frequency TMS can significantly reduce UPDRS motor scores compared with sham stimulations. On the other hand, low-frequency TMS studies showed no significant overall improvement in motor scores, mental scores or in the activities of daily living (ADL) UPDRS scores. Low-frequency and high-frequency TMS studies also showed no significant overall improvement in Schwab and England ADL scores. Conclusions TMS therapy is safe and partially effective for treating Parkinson's disease. Key words: Transcranial magnetic stimulation; Parkinson's disease; Meta-analysis

Subthalamic nucleus stimulation applied in the earlier vs. advanced stage of Parkinson's disease – Retrospective evaluation of postoperative independence in pursuing daily activities

While bilateral stimulation of the subthalamic nucleus (STN) has been commonly applied for patients with advanced Parkinson's disease (PD), surgery in the earlier stage of the disease may yield a better prognosis. We retrospectively analyzed the pre- and postoperative activities of daily living (ADL) of 38 PD patients who had undergone bilateral STN stimulation 3 months earlier. Preoperative Unified Parkinson's Disease Rating Scale (UPDRS) scores for neuropsychiatric, axial and ADL impairments were negatively correlated with the postoperative Schwab & England ADL (S–E) scale in the off-medication status ( p < 0.01). Patients with longer disease duration had a lower postoperative S–E scale, but their correlation was not statistically significant ( p = 0.0467). Age was not a significant predictor of postoperative ADL. Patients with a preoperative on-medication S–E scale ≤60% ( n = 14) manifested a greater response rate to surgery than did those with a preoperative S–E scale ≥70% ( n = 24). However, patients with poorer preoperative ADL were unable to perform ADL independently after surgery (postoperative S–E was 70.0 ± 12.4% in the on-, and 65.7 ± 16.0% in the off-medication status) and the difference from patients with better preoperative S–E was significant (postoperative S–E 92.5 ± 5.3% in the on-, and 90.4 ± 6.2% in the off-medication status) ( p < 0.0001). Our findings suggest that the delivery of STN stimulation earlier in the course of PD may result in greater independence in postoperative ADL.

Double‐blind trial of levodopa/carbidopa/entacapone versus levodopa/carbidopa in early Parkinson's disease

We performed a 39-week, randomized, double-blind, multicenter study to compare the efficacy, safety, and tolerability of levodopa/carbidopa/entacapone (LCE, Stalevo) with levodopa/carbidopa (LC, Sinemet IR) in patients with early Parkinson's disease (PD). Four hundred twenty-three patients with early PD warranting levodopa were randomly assigned to treatment with LCE 100/25/200 or LC 100/25 three-times daily. The adjusted mean difference in total Unified Parkinson's disease Rating Scale (UPDRS) Parts II and III between groups using the analysis of covariance model (prespecified primary outcome measure) was 1.7 (standard error = 0.84) points favoring LCE (P = 0.045). Significantly greater improvement with LCE compared with LC was also observed in UPDRS Part II activities of daily living (ADL) scores (P = 0.025), Schwab and England ADL scores (blinded rater, P = 0.003; subject, P = 0.006) and subject-reported Clinical Global Impression (CGI) scores (P = 0.047). There was no significant difference in UPDRS Part III or investigator-rated CGI scores. Wearing-off was observed in 29 (13.9%) subjects in the LCE group and 43 (20.0%) in the LC group (P = 0.099). Dyskinesia was observed in 11 (5.3%) subjects in the LCE group and 16 (7.4%) in the LC group (P = 0.367). Nausea and diarrhea were reported more frequently in the LCE group. LCE provided greater symptomatic benefit than LC and did not increase motor complications.

Comparison of unilateral pallidotomy and subthalamotomy findings in advanced idiopathic Parkinson's disease

A prospective, randomized, double-blind pilot study to compare the results of stereotactic unilateral pallidotomy and subthalamotomy in advanced idiopathic Parkinson's disease (PD) refractory to medical treatment was designed. Ten consecutive patients (mean age, 58.4 ± 6.8 years; 7 men, 3 women) with similar characteristics at the duration of disease (mean disease time, 8.4 ± 3.5 years), disabling motor fluctuations (Hoehn & Yahr stage 3–5 in off-drug phases) and levodopa-induced dyskinesias were selected. All patients had bilateral symptoms and their levodopa equivalent dosing were analysed. Six patients were operated on in the globus pallidus interna (GPi) and four in the subthalamic nucleus (STN). Clinical evaluation included the use of the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn&Yahr score and Schwab England activities of daily living (ADL) score in ‘on’- and ‘off’-drug conditions before surgery and 6 months after surgery. There was statistically significant improvement in all contralateral major parkinsonian motor signs in all patients followed for 6 months. Levodopa equivalent daily intake was significantly reduced in the STN group. Changes in UPDRS, Hoehn & Yahr and Schwab England ADL scores were similar in both groups. Cognitive functions were unchanged in both groups. Complications were observed in two patients: one had a left homonymous hemianopsia after pallidotomy and another one developed left hemiballistic movements 3 days after subthalamotomy which partly improved within 1 month with Valproate 1000 mg/day. The findings of this study suggest that lesions of the unilateral STN and GPi are equally effective treatment for patients with advanced PD refractory to medical treatment.

ELECTRODE POSITION DETERMINED BY FUSED IMAGES OF PREOPERATIVE AND POSTOPERATIVE MAGNETIC RESONANCE IMAGING AND SURGICAL OUTCOME AFTER SUBTHALAMIC NUCLEUS DEEP BRAIN STIMULATION

The electrode position is important to the surgical outcome after subthalamic nucleus (STN) deep brain stimulation (DBS). The aim of this study was to compare the surgical outcome of bilateral STN DBS with the electrode position estimated using fused magnetic resonance imaging. Bilateral STN DBS was performed in 60 patients with advanced Parkinson's disease. Patients were evaluated with the Unified Parkinson's Disease Rating Scale, Hoehn and Yahr staging, Schwab and England Activities of Daily Living, L-dopa equivalent dose, and Short Form-36 Health Survey before and at 3 and 6 months after surgery. Brain magnetic resonance imaging (1.5-T) was performed in 53 patients at 6 months after STN DBS. The electrode position was estimated in the fused pre- and postoperative magnetic resonance images and correlated with the surgical results. As a group, the Unified Parkinson's Disease Rating Scale, Hoehn and Yahr staging, Schwab and England Activities of Daily Living, and Short Form-36 Health Survey scores improved at 3 and 6 months after STN DBS. The L-dopa equivalent dose decreased by 60% at 3 and 6 months after STN DBS. The electrode position was divided into 6 types according to its relationship to the STN and the red nucleus. Most off-medication Unified Parkinson's Disease Rating Scale motor subscale scores improved regardless of the type of electrode position. The off-medication speech subscale score improved only in the patients whose electrodes were correctly positioned in the STN bilaterally. The electrodes accurately positioned in the STN led to improved speech after bilateral STN DBS. An effort should be made in each patient to document the electrode position to monitor surgical performance and to improve the surgical outcome after STN DBS.

STN DBS of Advanced Parkinson's Disease Experienced in a Specialized Monitoring Unit with a Prospective Protocol

In the evaluation of patients with Parkinson's disease (PD), most neurologists only see their patients during a limited period of their fluctuating 24-hour-a-day lives. This study aimed to assess the short-term outcome of STN stimulation for patients with advanced PD evaluated in a 24-hour monitoring unit for movement disorder (MUMD) using a prospective protocol. Forty-two patients with advanced PD consecutively treated with bilateral STN stimulation using multi-channel microelectrode recording were included in this study. All patients were evaluated using a 24-hour MUMD with a video recording/editing system and were evaluated with a prospective protocol of the Unified Parkinson's Disease Rating Scale, Hoehn and Yahr Staging, Schwab and England Activities of Daily Living, levodopa equivalent daily dose (LEDD), Short Form-36 Health Survey, and neuropsychological tests. Magnetic resonance (MR) images of the brain were performed prior to and six months after surgery. All patients were evaluated at three and six months after surgery. There was a rapid and significant improvement of the motor symptoms, especially in tremor and rigidity, after STN stimulation with low morbidity. Dyskinesia was markedly decreased with much lowered LEDD values by 50% after STN stimulation. 1.5T MR images were safely taken according to the manufacturer's guidelines at six months after surgery without any adverse effects in 41 patients treated with STN stimulations. Evaluations in a 24-hour monitoring unit could reduce the dose of medication efficiently to an optimal level with patients'comfort and improve the clinical symptoms in harmony with STN stimulation.

Open-Label Trial Regarding the Use of Acupuncture and Yin Tui Na in Parkinson's Disease Outpatients: A Pilot Study on Efficacy, Tolerability, and Quality of Life

This study evaluates the effects of sequential tui na massage, acupuncture, and instrument-delivered qigong for patients with Parkinson disease (PD) over a 6-month period. Patients received weekly treatments, which included tui na massage prior to acupuncture followed by instrument-delivered qigong. Each patient was assessed at baseline and at 6 months. The setting was an outpatient research/academic clinic for patients with PD and nonacademic acupuncture clinic. Twenty-five (25) patients with idiopathic PD were the subjects. Before and after treatment patients were evaluated with the Unified Parkinson Disease Rating Scale (UPDRS), Hoehn and Yahr Staging (H&Y), Schwab and England Activities of Daily Living (S & E), Beck Depression Inventory (BDI), Parkinson's Disease Questionnaire (PDQ-39) quality of life assessment, and patient global assessments. There were no significant improvements in treatment measures; however, there was a 2.4-point worsening in UPDRS motor scores (24.0 versus 26.4, p = 0.018). There was a 16% improvement in the PDQ- 39 total score (23.2 versus 19.6, p = 0.044) and a 29% improvement in the BDI (9.6 versus 6.8, p = 0.006). Sixteen (16) patients reported moderate to marked improvement. There were no adverse effects. Acupuncture is safe and well tolerated in patients with PD. Most patients reported subjective improvement. The BDI and PDQ-39 total score, measuring depression and quality of life, demonstrated some improvement, but UPDRS motor scores worsened.

Progression of multiple system atrophy (MSA): A prospective natural history study by the European MSA Study Group (EMSA SG)

The disease-specific Unified Multiple System Atrophy Rating Scale (UMSARS) has been developed recently and validated for assessing disease severity in multiple system atrophy (MSA). Here, we aimed at (1) assessing rates of disease progression in MSA and (2) validating UMSARS for sensitivity to change over time. Impairment was assessed at two time points 12 months apart using UMSARS Part I (historical review), UMSARS Part II (motor examination), as well as measures of global disease severity, including UMSARS Part IV, Hoehn and Yahr (HY) Parkinson's disease staging, Schwab England Activities of Daily Living (SE ADL), and a three-point global Severity Scale (SS3). Fifty patients (male:female ratio, 1:0.9; possible MSA, 16%; probable MSA, 84%; MSA-parkinsonian, 58%; MSA-cerebellar, 42%) were assessed twice with an interval of 12.3 months. UMSARS II scores progressed by 57.3% (P<0.0001) and UMSARS I scores by 35.6% (P<0.0001) in relation to the respective baseline scores with no differences between motor subtypes, diagnostic categories and gender. Significant inverse correlations between (1) UMSARS I or UMSARS II progression and (2) baseline disability measures (i.e., the respective UMSARS or SS3 scores) and disease duration were found. Furthermore, the increases in HY staging, SE ADL and SS3 correlated significantly with UMSARS I, UMSARS II, and UMSARS IV progression. This report is the first prospective study showing rapid annual UMSARS rates of decline in MSA. Our data contribute to the ongoing validation process of UMSARS, and they facilitate the planning and implementation of future neuroprotective intervention trials.

GPi pallidotomy for Parkinson's disease with drug-induced psychosis

Levodopa-induced psychosis may seriously threaten the ability of patients with Parkinson's disease (PD) to continue leading an independent life. A retrospective assessment of the therapeutic effects of the globus pallidus internus (GPi) pallidotomy on the activities of daily living (ADL) of seven PD patients presenting with mild or moderate degrees of psychosis was carried out. Their scores according to the Unified Parkinson's Disease Rating Scale (UPDRS) Part I-2 (maximum=4) were 2 or 3 (mean±SD=2.4±0.5). Bilateral procedure was needed in 5 out of 7 patients to obtain sufficient improvement of motor symptoms. At 3 months after surgery, UPDRS part III motor scores in the ‘off’ state were significantly decreased and motor fluctuations were abolished. Nevertheless, their score of Schwab and England (S–E) ADL scale scores responded poorly to the surgery, while the scores in other 12 patients without psychosis was significantly improved after pallidotomy. The data indicate that GPi pallidotomy ameliorates the motor symptoms in patients with drug-induced psychosis (DIP), but has no significant impact on their consequent daily activities. A regression model for all 19 patients who underwent pallidotomy revealed that postoperative S–E scale was affected by the preoperative UPDRS Part I-2 rather than by Part III motor score. The present study suggested that DIP, even if its degree is not severe, may be a limiting factor of the therapeutic potential of pallidotomy in patients with PD.

A double-blind, placebo-controlled and longitudinal study of riluzole in early Parkinson's disease

Background: To the extent that excitotoxicity may play a role in the pathogenesis of certain neurodegenerative disorders, antagonists of glutamate, an excitatory neurotransmitter, should exert neuroprotective effects in these disorders, including Parkinson's disease (PD). Methods: Patients in early stages of PD, not previously treated with levodopa, were randomized to receive riluzole 50 mg capsules orally, taken twice daily or a matching placebo. All subjects were evaluated at baseline (pre-treatment), at 1, 3 and 6 months (post-treatment), and following a 6-week washout. After the washout, all subjects were offered an enrollment in an open label, 1-year, extension study. The principal investigator (JJ), however, remained blinded to the original assignment during the entire study. The patients were assessed by the Unified Parkinson's Disease Rating Scale (UPDRS), Activities of Daily Living (ADL), Hoehn & Yahr (HY) stage, and Schwab and England (SE) ADL scale. The quantitative assessments included Movement Time (MT) and Reaction Time (RT). Additionally, the time to initiate dopaminergic therapy was assessed. Safety was determined at each visit by clinical history and examination, a panel of blood safety laboratory tests including complete blood count, chemistry profile, and liver function studies. Results: Twenty patients with a mean age of 62±9.02 (range: 46–73) years and mean duration of symptoms of 18±9.53 (range: 6–36) months were enrolled. One patient withdrew from the study because he needed more aggressive treatment of his symptoms. Analysis of the efficacy variables showed no meaningful symptomatic effect of riluzole on UPDRS score. Likewise, there was no significant change in the median HY stage, SE ADL rating, or the MT/RT. Seventeen patients (mean age 62±9.26) elected to continue in the open label extension study. Although the observed deterioration in UPDRS scores seemed to be more pronounced in the placebo group than in the riluzole group, the difference did not reach statistical significance. There was no statistically significant difference in the latency between enrollment and start of symptomatic therapy when patients initially treated with riluzole were compared to those initially treated with placebo (8.3 vs 9 months). Conclusions: This pilot and extension study showed that riluzole, 100 mg/day, was well tolerated in patients with early PD. No evidence of symptomatic effect of riluzole was observed. Because of the exploratory nature of the design and small size of the study, it was not possible to determine whether riluzole affected the natural history of PD. The encouraging results from our study, however, suggest that larger, longitudinal studies are warranted.

Deep brain stimulation of the subthalamic nucleus for control of extrapyramidal features in advanced idiopathic parkinson's disease: one year follow-up.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) with a quadripolar electrode was carried out in 9 patients with advanced idiopathic Parkinson's disease (PD) affected with severe diurnal motor fluctuations. The effect of bilateral STN stimulation was evaluated by clinical methods in all patients after 3 and 12 months. Assessment was based on the Unified Parkinson's Disease Rating Scale (UPDRS), timed motor tests, the Schwab and England Activities of Daily Living and a diary chart to document motor fluctuations. Alterations in parkinsonian signs, motor performance and functional outcome were recorded postoperatively (1) under temporary complete withdrawal of both STN stimulation and medication; (2) in the presence of STN stimulation only; and (3) in the presence of both STN stimulation and medication. The results were compared with the preoperative data assessed in defined on-phase and defined off-phase. STN stimulation on (compared to STN stimulation off) results in a significant improvement in UPDRS motor scores: after 3 months from 50.5 +/- 14.3 to 27.8 +/- 5.8, and after 12 months from 49.4 +/- 14.1 to 27.1 +/- 7.1 (p < 0.01). There was a significant decrease in the average duration of off-periods from 8.82 +/- 2.47 hours to 1.00 +/- 1.06 hours (p < 0.001), a marked increase in on-periods without dyskinesia from 4.62 +/- 2.72 to 14.62 +/- 1.51 hours (p < 0.01), and a sharp drop in on-periods with dyskinesia from 2.87 (+/- 4.18) to 0.25 (+/- 0.97) hours (p < 0.05), which remained stable up to 12 months (off-periods: 1.25 +/- 1.58 hours, p < 0.001; on-periods without: 13.87 +/- 1.95 hours, p < 0.001; and on-periods wth dyskinesia: 0.37 +/- 1.06 hours, p < 0.05). However, our first PD patient with an implanted DBS electrode within the STN died from cardiac infarction two days after surgery. This sudden death was not linked either to surgery nor to stimulation - and happened by chance. Our findings confirm that STN stimulation is a suitable functional neurosurgical procedure for the modulation and control of PD signs associated with severe motor fluctuations, in that they demonstrate a beneficial effect which was fully sustained over a one year follow-up period. Subthalamic nucleus, deep brain stimulation, Parkinson's disease.

Prevalence of a history of shaking in persons 65 years of age and older: diagnostic and functional correlates.

The purpose of this study was to determine the prevalence and functional and diagnostic correlates of reported shaking in the community-dwelling elderly. We conducted a standardized neurological evaluation of 1,056 nondemented Medicare recipients in Washington Heights-Inwood, Northern Manhattan (New York). Of 1,056 patients, 108 reported shaking (10.2%). The prevalence of reported shaking did not increase with age. It did differ between ethnic groups, but when adjusted for depression and score on the Schwab and England Activities of Daily Living (ADL) scale, this difference was insignificant. The age-adjusted prevalence was similar for women and men. Neurological examination of the 108 who reported shaking showed that 8.3% had tremor at rest, 17.6% had tremor with action, 5.6% had dyskinesia or chorea, and an additional 28.7% had various problems in coordination or movement. The remaining 39.8% had neither tremor nor problems in coordination or movement. Only 2.9% of individuals with reported shaking had Parkinson's disease (PD), 8.7% had essential tremor, and 2.1% had oral-buccal-lingual dyskinesia. Of the remaining 86.3%, 29 (31%) had no identifiable medical condition. Those who reported shaking were less independent with ADLs, regardless of presence of tremor on examination. Shaking is commonly reported by the community-dwelling elderly. It does not necessarily identify individuals with essential tremor and PD, and is related to decreased independence in ADLs.

Kaposi's sarcoma: histopathological study of 159 cases from Malawi.

The histological features of 168 lesions of Kaposi's sarcoma from 159 patients in Malawi, where the disease is commoner than elsewhere, were characteristic. All showed well-developed areas of tumour and could be grouped fairly readily into those with a mixed pattern, a predominantly spindle cell pattern, and an anaplastic group, though intermediate patterns were seen. Hyaline bodies were present in nearly all tumours of skin. The cell of origin of Kaposi's sarcoma is uncertain and possibly has multipotential capabilities. Differential diagnosis may be difficult. Clinically the lesion may be confused with granuloma pyogenicum and may also be like it histologically. The presence of hyaline bodies and deposits of haemosiderin indicate Kaposi's sarcoma. The spindle cell predominant type may be confused with leiomyoma, leiomyosarcoma, or fibrosarcoma. The presence of hyaline bodies and the formation of vascular channels between spindle cells point to a diagnosis of Kaposi's sarcoma.