Movement Disorders Fellowship Research Articles

Abhimanyu Mahajan, MD, MHS, and Ludy C. Shih, MD, MMSc, FAAN, FANA

Dr. Abhimanyu Mahajan is Assistant Professor of Neurological Sciences in the Rush Parkinson's Disease and Movement Disorders program at Rush University Medical Center in Chicago, IL. After medical school in Mumbai, India, Dr. Mahajan obtained a Masters in Epidemiology with a concentration in aging at the Johns Hopkins Bloomberg School of Public Health and a certificate in gerontology from the Johns Hopkins Center of Aging and Health in Baltimore, MD. He completed his Neurology Residency at Henry Ford Hospital in Detroit and Movement Disorders fellowship at the University of Cincinnati, where he was the 2019 Dystonia Medical Research Foundation (DMRF) clinical fellow. Dr. Mahajan has received funding from the DMRF, Sunflower Parkinson's Disease Foundation, and the Parkinson's Foundation. He is a member of the 2022 Movement Disorders Society (MDS) LEAP class. For his work on cervical dystonia and substance abuse using the Dystonia Coalition database, he received the 2018 American Academy of Neurology (AAN) Young Investigators Award. He received the 2018 Junior Investigator Award from the Parkinson Study Group for his work using magnetoencephalography in cervical dystonia. His efforts on exploring the clinical relationship between cancer and Parkinson's disease, biological opposites, led to the 2020 AAN Alliance Award: Founders. Currently, he serves on the AAN Graduate Education Subcommittee, AAN Movement Disorders Measurement Workgroup, and the MDS Dystonia Study Group.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Movement Disorders Virtual Fellowship Training in Times of Coronavirus Disease 2019: A Single-Center Experience.

Objective: To describe the impact a global pandemic has had on a teaching movement disorders program, as well as its subsequent transition to telemedicine. Methods: In the midst of the coronavirus disease 2019 (COVID-19) pandemic, we transitioned our movement disorders fellowship program virtually over the course of a few days. Here we describe the parameters used for the telemedicine fellow supervised clinic visit over the course of 2 months. Fellow's input was obtained from a brief survey at the end of the experience. Faculty's experience was collected upon independent faculty discussions. We also summarize the challenges and advantages of this teaching experience and its downsides. Results: A total of 130 patients (102 follow-up and 28 new patients) were seen over 22 clinic days with any of our 3 fellows being supervised by 1 of the 6 attending physicians. The main challenges were related to technical difficulties and lack of portions of the examination such as tone, reflexes, and sensory testing. The main advantages were related to increased patient access and a decrease in scheduling barriers. The overall satisfaction with the experience of the fellows was positive (69%). Conclusions: This sample shows the feasibility (despite lack of prior experience) of virtual clinical supervision of movement disorders fellows for follow-up and new complex patient encounters. This novel method for movement disorders training has implications for training locally, nationally, and internationally. Limitations and possible future directions such as the inclusion of nonsynchronous recordings and devices for tone and balance testing are also discussed.

Mobile Application for Parkinson's Disease Deep Brain Stimulation (MAP DBS): An Open-Label, Multicenter, Randomized, Controlled Clinical Trial

Mobile Application for Parkinson's Disease Deep Brain Stimulation (MAP DBS): An Open-Label, Multicenter, Randomized, Controlled Clinical Trial

Editorial introductions

Current Opinion in Neurology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of neurology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Stéphane LehéricyStéphane LehéricyStéphane Lehéricy is Professor of Neuroradiology in the Salpêtrière hospital (PUPH), France. He has completed his PhD in basic neuroscience studying the pathophysiology of Alzheimer's disease (Yves Agid, Inserm, Paris, France), a post-doc in functional neuroimaging at SHFJ-CEA (Denis Le Bihan, Orsay, France). He spent about three years at the Centre for Magnetic Resonance Research, University of Minnesota, Minneapolis, USA (Kamil Ugurbil) studying basal ganglia function using high field MRI. Together with Pr Marie Vidailhet, Prof. Lehericy is co-head of the research team ‘Movement, Investigations and Therapeutics’ at Paris Brain Institute (ICM – Institut Cerveau Moelle, France). He also heads the Centre for NeuroImaging Research (CENIR), the ICM imaging platform and the Department of Neuroradiology of the Salpêtrière hospital. Dr Lehericy's scientific interest is in the study of the physiology of motor control and pathophysiology of movement disorders (focus on Parkinson's disease), neuroimaging and data analysis. His focus is on the functional organisation of the human motor system. He has contributed to the understanding of the functional and anatomical circuitry of the basal ganglia and of network dysfunction in movement disorders and particularly Parkinson's disease using multimodal MRI. Nutan SharmaNutan SharmaNutan Sharma, MD PhD, established the Dystonia Center for comprehensive care of patients with dystonia with sites at both Massachusetts General Hospital and Brigham and Woman's Hospital. The Center integrates information obtained from the systematic examination and treatment of patients with research regarding the pathophysiology of dystonia. Dr Sharma is the Principal Investigator of the Clinical Core of an NIH-funded P01 grant, “Molecular Etiology of Early Onset Torsion Dystonia’. The P01 supports: (1) systematic clinical evaluation as part of a longitudinal study of the natural history of dystonia; (2) collection of families with dystonia, obtaining both DNA and systematic clinical examination data, to help identify as yet unidentified dystonia causing genes. This work has led to the identification of mutations in GNAL as a cause of dystonia and contributed to the characterization of the phenotypic spectrum and response to treatment associated with KMT2B and ADCY5 mutations; (3) fMRI studies to evaluate white matter microstructure in those with focal dystonia. The genetic studies are in collaboration with Dr Laurie Ozelius. Dr Sharma is also a member of the Collaborative Center for the study of X-linked Dystonia-Parkinsonism (XDP). The XDP Center serves to fund research and medical care for those with XDP. The objectives of the Center include: (1) Identification and enrollment of patients with XDP and their families, including DNA isolation, generation of lymphoblast, fibroblast and iPS cell lines and (2) laboratory research that is conducted both at MGH and by other investigators, at various institutions throughout the world, who are invited to apply for funding that is then reviewed by a scientific advisory board. Dr Sharma established a natural history study protocol, with quantitative, cost-effective bedside measures that provide sensitivity and specificity in monitoring the course of XDP. Dr Sharma received her MD and PhD from the State University of New York at Stony Brook, USA. After completing a neurology residency at Yale University, USA, she completed a fellowship in movement disorders at Massachusetts General Hospital. She has received many grants for her work from research organizations including the NIH, the National Parkinson's Foundation and the Congressionally Directed Medical Research Program.

Editorial introductions

Current Opinion in Neurology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of neurology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Professor Bogdan DraganskiProfessor Bogdan DraganskiProfessor Bogdan Draganski is Consultant Neurologist at the Neurology Service–Department of Clinical Neurosciences, University Hospital Lausanne, Switzerland and Director of the neuroimaging laboratory LREN. After qualifying in Clinical Neurology in Germany he spent time working on computational anatomy research at the Institute of Neurology, UCL London, UK, followed by research at the Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig Germany. Bogdan Draganski pioneered computational anatomy research in use-dependent brain plasticity, developed and established new methods to investigate the structure and function of the brain. He conceived the speculative idea that local structure in the mature human brain may change in response to training and learning. Data he published first confirmed this to be a very germane idea that led to a new area of research exploring use-dependant plasticity. His ongoing projects are in the field of neurodegenerative disorders with particular emphasis on the identification of surrogate imaging biomarkers in the presymptomatic phase of brain diseases as an aid to the development of new therapeutic approaches especially in the field of deep brain stimulation (DBS). His wide-ranging research interests span autism, movement disorders and epilepsy. The neuroimaging laboratory he leads develops new magnetic-resonance imaging- based techniques to go deeper and understand the biological phenomenon underlying hippocampal neurogenesis and its impact on individual's memory performance. Renato Puppi MunhozRenato Puppi MunhozRenato Puppi Munhoz is an attending neurologist in the University Health Network and Mount Sinai Hospital, as well as Movement Disorders specialist in the Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease at the Toronto Western Hospital, University of Toronto where he is part of the surgical and ataxia clinics. Dr Munhoz is Associate Professor of Neurology in the University of Toronto. He received his Medical Doctor degree at the Federal University of Parana, Brazil, and completed Internal Medicine and Neurology residencies at the Pontifical Catholic Univeristy of Parana, serving as Chief Resident. He completed his Clinical Fellowship in Movement Disorders in the Movement Disorders Centre of the Toronto Western Hospital, serving as Chief Fellow, under the supervision of Dr Anthony Lang, in 2003. He obtained MSc and PhD degrees at the Federal University of Parana in 2008 and 2014, under the supervision of Dr Helio Teive. His clinical and research interests are focused on the clinical aspects of movement disorders, specially related to more common disorders such as parkinsonian syndromes, as well as novel forms of intervention, including neuromodulation.

The Current State and Needs of North American Movement Disorders Fellowship Programs

Background. Movement disorders fellowships are an important source of future clinician-specialists and clinician-scientists for the field. Scant published information exists on the number and characteristics of North American movement disorders fellowship training programs. Methods. A 31-item internet-based survey was formulated and distributed to academic movement disorders listed in the American Academy of Neurology (AAN) directory as having a movement disorders fellowship and to all National Parkinson Foundation Centers of Excellence and Care Centers in North America. Results. There was a 77% response rate among academic movement disorders centers. Broad similarities in clinical training were identified. The two most important rated missions of maintaining a movement disorders fellowship were contributions to scholarly activities and to fulfilling a critical need for specialists. Almost a quarter of fellowship programs did not offer a fellowship slot during the most recent academic year. Fellowship directors cited a wide variety of funding sources, but their top concern was lack of available funding for fellowship programs. Conclusions. North American movement disorders fellowship training programs currently offer similar methods of clinical training and education. Lack of funding was the most important obstacle to maintaining fellowship programs and should be made a priority for discussion in the field.

The Case for Subspecialization in Neurology: Movement Disorders

Within the world of medicine, the advent of new treatments and new technology has resulted in an increase in the number of specialties and subspecialties. This is especially true in neurology. A widely quoted article has demonstrated that 74% of neurology residents will do a fellowship (Larson et al., 2000), and given that the survey was done over 10 years ago, the number increased, as the most recent AAN resident survey gives a number of almost 78% (Resident Survey, 2008). Movement disorders is one of the many neurology fellowships that is non-accredited. On the AAN webpage there are currently 44 programs listed in the United States and Canada that offer a movement disorders fellowship (Directory for Fellowship Positions: American Academy of Neurology, 2010). The AAN resident survey reported that 9% of residents going into a fellowship chose movement disorders (Resident Survey, 2008). The question under consideration is to determine when a general neurologist should refer a patient to a movement disorders specialist.

Perceptual characteristics of Parkinsonian speech: A comparison of the pharmacological effects of levodopa across speech and non-speech motor systems

The purpose of this study was to: (1) define perceptual speech characteristics of idiopathic Parkinson disease (IPD) across 35 speech dimensions adapted from Darley et al. [19] and grouped under six speech-sign clusters (respiration, phonation, resonance, articulation, prosody and rate); (2) examine the effects of levodopa on the 35 perceptual speech dimensions and speech-sign clusters; and (3) to compare the relative effectiveness of levodopa on global motor functioning vs. speech production. Sixteen patients with IPD read the 'Grandfather Passage' both 'on' and 'off' levodopa. Three blinded speech-language pathologists performed perceptual speech analyses using a seven-point scale. The diagnosis of IPD was made by a movement disorders fellowship trained neurologist who applied UK Brain bank criteria and administered the Unified Parkinson Disease Rating Scale. Concordant with previous studies, the results of this experiment indicated that IPD disrupted multiple speech production subsystems, with prosody being the most severely affected domain. The perceptual dimensions that were most severely affected included: (1) sound imprecision; (2) mono-loudness; (3) mono-pitch; (4) reduced stress and (5) harsh voice. No significant differences were obtained between medicated states ('on'/'off') for any of the 35 individual speech dimensions and speech-sign clusters. Global motor function significantly improved following dopaminergic medications.

Eduardo Tolosa: from Spain to the USA and back again

Eduardo Tolosa: from Spain to the USA and back again

Movement disorders fellowship training program at Columbia University Medical Center in 2001–2002

Data regarding the clinical experience of movement disorders subspecialty training are currently not available. In order to provide information to help design a well-rounded clinical experience, we reviewed the number and types of patients seen by all clinical movement disorders fellows over the course of 1 year at Columbia University Medical Center (CUMC). We conducted a retrospective analysis of all patients seen by four full-time clinical fellows and one part-time fellow during the 2001-2002 academic year, using billing records to tabulate all clinic visits and patient charts to certify diagnosis. One thousand six hundred sixty-two patients (1,132 new and 530 follow-ups) were seen by five fellows. Each full-time fellow evaluated and treated a mean of 263 new patients, 116 follow-up patients, and 15 in-patient consultations. The part-time clinical fellow evaluated and treated 81 new patients and 65 follow-up patients. Approximately half of the new patients had idiopathic Parkinson's disease. Full-time fellows saw equivalent numbers of patients but they evaluated few patients with uncommon movement disorders. Weekly video rounds allowed all fellows to see many more patients, aiding the recognition of movement phenomenology and enhancing understanding of diagnoses and treatment strategies. Thus, CUMC fellows evaluate a large number of patients with a wide range of diagnoses within a 1-year period. Video rounds allow greater exposure to uncommon diagnoses. Similar data from other movement disorder training programs are needed to help create guidelines for formal accreditation and to improve clinical training in this subspecialty.

Elan D. Louis

[Author Photo]The readers and staff of Seminars in Neurology are privileged to be provided with an outstanding issue on the neurological exam and its historical background under the guest editorship of Dr. Elan D. Louis. Dr. Louis is an Assistant Professor of Neurology at the Sergeivsky Center and Department of Neurology at the College of Physicians and Surgeons, Columbia University. After receiving his undergraduate degree from the University of Pennsylvania, he attended medical school at Yale and then received a masters degree in epidemiology from the Columbia University School of Public Health. He spent a year at the Cold Spring Harbor Laboratory in the Eukaryotic Molecular Genetics Section and then obtained residency training in neurology at the New York Neurological Institute at Columbia-Presbyterian Medical Center, followed by a fellowship in movement disorders and neuroepidemiology.