Motor Examination Research Articles

Outcome of End to Side Nerve Modified Double Oberlin Procedure and End to End Dorsal Approach Spinal Accessory to Suprascapular Nerve in Partial Postganglionic BPI: A Case Report

Introduction: Brachial plexus injury (BPI) is a devastating peripheral nerve injury that mostly affecting young men, often due to motor vehicle accidents. BPIs can be classified into preganglionic and postganglionic lesions, with postganglionic injuries allowing potential nerve regeneration. The Oberlin method, aimed at reinnervating the biceps, and the Mackinnon technique, targeting both biceps and brachialis muscles, have shown promising outcomes in BPI management. Case report: A 45-year-old man presented with right hand weakness and occasional tingling in the upper arm and fingers two months after a motorcycle accident. Motor examination revealed muscle strength of 0/5 in the right trapezius, rhomboids, serratus anterior (positive winging scapula), pectoralis minor and major, latissimus dorsi, deltoid, biceps, and elbow flexion. Wrist and finger functions remained intact. Diagnosed with post-ganglionic BPI, the patient underwent two nerve transfer surgeries: the Mackinnon technique, transferring the spinal accessory nerve to the suprascapular nerve to reinnervate shoulder muscles, and the Double Oberlin procedure, transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve for reinnervation of the biceps and brachialis muscles. Post-surgery, the patient engaged in an aggressive rehabilitation program focusing on strength, range of motion, and sensory re-education. Over nine months, the patient showed significant improvement in elbow flexion (MRC grade 3), wrist extension (MRC grade 5), hand grip strength (MRC grade 3) with improved sensation across the affected limb. He returned to work and daily activities with mild residual weakness and sensory deficits. Discussion: This case illustrates the effectiveness of the Mackinnon and Double Oberlin nerve transfer techniques in restoring function in a patient with total post-ganglionic BPI. The Mackinnon technique enabled shoulder muscle reinnervation, essential for abduction and stabilization, while the Double Oberlin procedure enhanced elbow flexion by reinnervating both the biceps and brachialis muscles. The combined surgical and intensive rehabilitation approach facilitated significant functional recovery. Conclusion: The successful application of the Double Oberlin and Mackinnon techniques in this case demonstrates their potential in managing total post-ganglionic BPI. Early surgical intervention and consistent rehabilitation are crucial for optimizing recovery outcomes. This case highlights the importance of a multidisciplinary approach in treating complex peripheral nerve injuries. Keywords: Double Oberlin, Mackinnon, Brachial Plexus Injury

The correlation of neurosurgery motor examinations with ISNCSCI motor examinations in patients with spinal cord injury: a multicenter TRACK-SCI study.

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) assessment is the gold standard for evaluation of neurological function after spinal cord injury (SCI). Although it is an invaluable tool for diagnostic and research purposes, it is time consuming and can be impractical in acute injury settings. Clinical neurosurgery motor examinations (NMEs) could serve as an expeditious surrogate for SCI research when ISNCSCI motor examinations are not feasible. The aim of this study was to evaluate the agreement between motor examinations performed by the neurosurgery clinical team and ISNCSCI examiners. The multicenter prospective Transforming Research and Clinical Knowledge in Spinal Cord Injury (TRACK-SCI) registry was queried to identify patients with recorded neurosurgery and research motor examinations within 24 hours of each other. Pearson correlations and modified Bland-Altman analyses were performed using data from matching upper-extremity, lower-extremity, and combined examinations. Kappa analysis was used to test interrater reliability with respect to determination of American Spinal Injury Association Impairment Scale (AIS) grade. There were 72 pairs of matching clinical and research examinations in 63 patients. NME scores were strongly correlated with ISNCSCI motor scores (R = 0.962, p < 0.001). Both upper- and lower-extremity NME scores were strongly correlated with upper- and lower-extremity ISNCSCI motor scores, respectively (R = 0.939, p < 0.001; and R = 0.959, p < 0.001, respectively). In modified Bland-Altman analyses, total, upper-extremity, and lower-extremity NME scores and ISNCSCI motor scores showed low systematic bias and high agreeability (total: bias = 0.3, limit of agreement [LoA] = 36.6; upper extremity: bias = -0.5, LoA = 17.6; lower extremity: bias = 0.8, LoA = 24.0). There were 66 pairs of examinations that had thorough sensory and rectal examinations for AIS grade calculation. Using kappa analysis to test the interrater reliability of AIS grade calculation using NME versus ISNCSCI motor scores, the authors found a weighted kappa of 0.883 (SE 0.061, 95% CI 0.736-0.976), indicating strong agreement. Overall, this study suggests that ISNCSCI motor scores and NME scores are strongly correlated and highly agreeable. When conducting SCI research, a thorough clinical motor examination may be a useful surrogate when ISNCSCI examinations are missing.

A - 103 Exploring the Diagnostic Criteria for Alcohol-Related Dementia: a Case Study

Abstract Objective Excessive and chronic alcohol use can cause structural/functional abnormalities in the brain, including cognitive impairment (CI) (Harper, 2009). Despite these established risks, alcohol-related dementia (ARD) has received little recognition, mainly due to lack of a distinct pathophysiological profile. Through a case differential approach (concussion vs. ARD), the authors aim to clarify diagnostic criteria for ARD. Methods A 56-year-old right-handed male presented to the emergency room after fall with head strike (no loss of consciousness) with alcohol withdrawal delirium. Symptoms of cerebellar ataxia and CI of 6-month duration were noted. Past medical history was significant for alcohol use (four standard units per day), hyperlipidemia, tobacco use, and depression/anxiety. Neuroimaging revealed cerebral atrophy and chronic small vessel ischemic disease. A neuropsychological evaluation (NPE) was conducted 18 days post-fall. Results NPE revealed relative weaknesses in working memory, complex attention, and visual abstraction. Impairments were noted in visuospatial organization/planning, processing speed, basic attention, verbal fluency, and verbal memory. Motor examination was evident for intention tremor. Conclusion Brain changes associated with ARD include volume loss, altered glucose metabolism, reduced neuronal density, changes in frontal lobe function, and white matter loss. In contrast, individuals affected by concussions may encounter challenges with attention/concentration, processing speed, and working memory. Distinguishing a clear diagnostic profile for ARD is difficult due to high rates of concomitant concussion in this population. The patient’s deficits exceed those expected due to concussion alone, with an anticipated cognitive recovery timeframe of 7–14 days (Iverson, 2006). Furthermore, neuroimaging and NPE results support the diagnostic hypothesis of ARD.

Longitudinal Changes of Clinical, Imaging, and Fluid Biomarkers in Preataxic and Early Ataxic Spinocerebellar Ataxia Type 2 and 7 Carriers.

Brain MRI abnormalities and increases in neurofilament light chain (NfL) have mostly been observed in cross-sectional studies before ataxia onset in polyglutamine spinocerebellar ataxias. Our study aimed to identify longitudinal changes in biological, clinical, and/or imaging biomarkers in spinocerebellar ataxia (SCA) 2 and SCA7 carriers over 1 year. We studied SCA2 and SCA7 carriers and controls (expansion-negative relatives) at the Paris Brain Institute. Inclusion criteria included Scale for the Assessment and Rating of Ataxia (SARA) scores between 0 and 15. Assessments at baseline, 6 months, and 12 months comprised neurologic, quality of life, orofacial motor, neuropsychological, and ophthalmologic examinations, along with gait and oculomotor recordings, brain MRI, CSF, and blood sampling. The primary outcome was the longitudinal change in these assessments over 1 year. We included 15 SCA2 carriers, 15 SCA7 carriers, and 10 controls between May 2020 and April 2021. At baseline, the ages were similar (41 [37, 46] for SCA2, 38 [28.5, 39.8] for SCA7, and 39.5 [31, 54.5] for controls, p = 0.78), as well the sex (p = 0.61); SARA scores were low but different (4 [1.25, 6.5] in SCA2, 2 [0, 11.5] in SCA7, and 0 in controls, p < 0.01). Pons and medulla volumes were smaller in SCAs (p < 0.05) and cerebellum volume only in SCA2 (p = 0.01). Plasma NfL levels were higher in SCA participants (SCA2: 14.2 pg/mL [11.52, 15.89], SCA7: 15.53 [13.27, 23.23]) than in controls (4.88 [3.56, 6.17], p < 0.001). After 1-year follow-up, in SCA2, there was significant pons (-144 ± 60 mm3) and cerebellum (-1,508 ± 580 mm3) volume loss and a worsening of gait assessment; in SCA7, SARA score significantly increased (+1.3 ± 0.4) and outer retinal nuclear layer thickness decreased (-15.4 ± 1.6 μm); for both SCA groups, the orofacial motor assessment significantly worsened. For preataxic and early ataxic carriers, the strongest longitudinal deterioration on outcome measures was orofacial motility in SCA2 and retinal thickness in SCA7. Despite the limitation of the small sample size, we detected annual changes in preataxic and early ataxic SCA individuals across brain MRI imaging, clinical scores, gait parameters, and retinal thickness. These parameters could serve as potential end points for future therapeutic trials in the preataxic phase. ClinicalTrials.gov NCT04288128.

Sparse item testing of clinical scales in neurology trials to alleviate burden to patients.

Neurology trials typically rely on composite scales for measuring symptom severity. Completing all items in a long scale can be burdensome for patients, caregivers, and trial personnel. To test the hypothesis that sparse item testing, aided by item-response modelling, can preserve the power for detecting treatment effect in a controlled trial. UPDRS (Unified Parkinson's Disease Rating Scale) Part III (motor examinations) data from a placebo-controlled trial (N = 391) of ropinirole were analysed with a longitudinal item-response model. Symptom severity was estimated directly from item scores as a latent variable, without needing the total score. This enabled sparse item testing. With the symptom severity as a clinical endpoint, the potential power loss for detecting treatment effect due to the sparse testing was assessed by simulation. When each patient took 18 of all 27 tests in UPDRS Part III at each study visit, there was no appreciable power loss. Reducing four visits to three also had negligible effects on power. A threefold reduction of the total tests that each patient needed to do throughout the trial, from 108 to 27, only compromised power slightly, e.g., from 92 to 87% at N = 160. These findings show that using the symptom severity derived from item scores as the endpoint allows sparse testing to drastically reduce trial burden without incurring major power loss. This benefit would multiply for indications like Alzheimer's disease where modern trials often require patients to be tested on multiple scales at several times.

A case of MERS presenting with acute motor aphasia and tetraparesis and literature review

BackgroundMild encephalopathy wıth reversible splenial lesions (MERS) are a clinical–radiological diagnosis that can be diagnosed with radiological imaging and can be accompanied by impaired consciousness, aphasia, headache, and paralysis. MERS can be divided into two different types based on radiological findings; Involvement of the splenium is seen in type 1, and involvement of the splenium and deep white matter is seen in type 2. MERS Type 2 is very rare in adults. Here, we describe a patient diagnosed with MERS Type 2 and our therapeutic intervention.Case presentationA 22-year-old woman presented with slurred speech, weakness in the extremities and headache that started 14 h ago. The patient had sore throat and fever of 37.6 °C for 2 days, and medical history or family history were unremarkable. Neurological examination revealed that she was conscious, cooperative, with no signs of meningeal irritation. Speech comprehension, naming, and repetition were preserved, motor examination revealed 5/5 left upper extremity strength, 4/5 right upper extremity strength, and 2/5 bilateral lower extremity strength. Diffusion-weighted magnetic resonance imaging (MRI-DWI) revealed bilateral deep white matter and splenium symmetrical diffusion restriction. Blood tests showed high C-reactive protein (CRP) and no leukocytosis. No cells were detected in the cerebrospinal fluid (CSF), protein was 151 mg/dl, glucose was within normal limits. The patient, who developed quadriparesis during follow-up, was started on pulse dose steroids. Neurological examination improved to patient’s baseline at the 12th hour of treatment. In the 72nd hour control MRI-DWI, it was seen that the lesions had regressed. Culture/Polymerase chain reaction (PCR) for bacterial/viral infection agents came back negative. After steroids were given for 5 days, patient was discharged at her baseline.ConclusionsMERS is a rare diagnosis in adults and can be radiologically confused with acute toxic leukoencephalopathy. It can be distinguished clinically by the absence of prior infection, fever, and toxic agent exposure. Although there is no consensus in the literature regarding the treatment, the clinical picture improved rapidly after steroid in our case. Despite being rare, it should be considered in the differential diagnosis of patients with deep white matter lesions in adults.

Virtual reality: a game-changer in the diagnosis and surgical planning of astrocytoma grade III: a case report

BackgroundIn the dynamic realm of modern medicine, the advent of virtual reality technology heralds a transformative era, reshaping the contours of diagnosis and surgical planning with its immersive prowess. This study delves into the groundbreaking application of virtual reality in the intricate dance of neurosurgery, particularly spotlighting its role in the management of astrocytoma grade III—a cerebral challenge of significant complexity.Case presentationA 30-year-old Middle Eastern man from Syria grappled with the invisible tendrils of pain, manifesting as persistent headaches and a numbing sensation that crept into his neck and extremities. For two relentless months, the morning sun brought not hope but an intensification of his agony, rendering him unable to partake in the daily dance of life. The usual sentinels of relief, analgesic drugs, stood defeated, offering no respite. The neurological examination was normal, there were no pathological findings on sensory and motor examination, and he exhibited normal reflexes and neither meningeal nor cerebellar signs. He showed a family history of breast cancer. The initial foray into the enigmatic depths of his brain via computed tomography and magnetic resonance imaging imaging unveiled a finding in the right temporal lobe, a lesion that suggested something more sinister. Previous medical interventions included analgesic medications prescribed for persistent headaches, but they offered no relief. No other therapeutic interventions were administered prior to the current diagnosis. It was here that virtual reality technology emerged not as a mere tool but as a beacon of precision, casting a three-dimensional light on the shadowy intruder. This technological marvel allowed for meticulous measurement 21.8 × 14.5 mm and localization within the temporal theater, setting the stage for what was to come. With the path laid clear, the patient embarked on a surgical odyssey, a quest to excise the unwelcome guest. The operation was a triumph, a testament to human ingenuity and the symbiotic relationship between flesh and machine. The postoperative verdict was delivered through the lens of histopathology, confirming the presence of an astrocytoma grade III, a cerebral interloper known for its rapid proliferation. The battle, however, was far from over. Complementary radiotherapy and chemotherapy were enlisted as allies in this ongoing war, their potent forces working in concert to stave off the cellular insurgence. The patient’s journey through the healing arts was charted by periodic clinical and neurological examinations, with laboratory tests and the vigilant gaze of brain magnetic resonance imaging ensuring a watchful eye was kept on any potential resurgence.ConclusionsIn this narrative of resilience and technological prowess, we witness the harmonious fusion of human touch and digital precision, a partnership that redefines the boundaries of medicine and the art of healing, by use of virtual reality technology in the diagnosis of astrocytoma and enhancing the accuracy, effectiveness, and safety of neurosurgical procedures, which can ultimately benefit patients with brain tumors.

Validation of the hotspot for dorsolateral subthalamic nucleus targeting in deep brain stimulation surgery for Parkinson’s disease: a post hoc analysis of a randomised controlled trial

BackgroundVisualisation of the dorsolateral subthalamic nucleus (STN) remains challenging on 1.5 and 3Tesla T2-weighted MRI. Our previously defined hotspot, relative to the well-visualised medial STN border, serves as an MRI...

Skin α-Synuclein Seeding Activity in Patients with Type 1 Gaucher Disease.

Patients with type 1 Gaucher disease (GD1) have a significantly increased risk of developing Parkinson's disease (PD). The objective of this study was to evaluate skin α-synuclein (αSyn) seeding activity as a biomarker for GD1-related PD (GD1-PD). This single-center study administered motor and cognitive examinations and questionnaires of nonmotor symptoms to adult patients with GD1. Optional skin biopsy was performed for skin αSyn seed amplification assay (αSyn SAA) using real-time quaking-induced conversion assay. Forty-nine patients were enrolled, and 36 underwent skin biopsy. Two study participants had PD. Ten participants were αSyn SAA positive (27.8%), 7 (19.4%) were intermediate, and 19 (52.8%) were negative. Positive αSyn seeding activity was observed in the single GD1-PD case who consented to biopsy. αSyn SAA positivity was associated with older age (p = 0.043), although αSyn SAA positivity was more prevalent in patients with GD1 than historic controls. Longitudinal follow-up is required to determine whether skin αSyn seeding activity can be an early biomarker for GD1-PD. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Effects of home-based EEG neurofeedback training as a non-pharmacological intervention for Parkinson's disease

ObjectivesAberrant movement-related cortical activity has been linked to impaired motor function in Parkinson's disease (PD). Dopaminergic drug treatment can restore these, but dosages and long-term treatment are limited by adverse side-effects. Effective non-pharmacological treatments could help reduce reliance on drugs. This experiment reports the first study of home-based electroencephalographic (EEG) neurofeedback training as a non-pharmacological candidate treatment for PD. Our primary aim was to test the feasibility of our EEG neurofeedback intervention in a home setting. MethodsSixteen people with PD received six home visits comprising symptomology self-reports, a standardised motor assessment, and a precision handgrip force production task while EEG was recorded (visits 1, 2 and 6); and 3 × 1-hr EEG neurofeedback training sessions to supress the EEG mu rhythm before initiating handgrip movements (visits 3 to 5). ResultsParticipants successfully learned to self-regulate mu activity, and this appeared to expedite the initiation of precision movements (i.e., time to reach target handgrip force off-medication pre-intervention = 628 ms, off-medication post-intervention = 564 ms). There was no evidence of wider symptomology reduction (e.g., Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III Motor Examination, off-medication pre-intervention = 29.00, off-medication post intervention = 30.07). Interviews indicated that the intervention was well-received. ConclusionBased on the significant effect of neurofeedback on movement-related cortical activity, positive qualitative reports from participants, and a suggestive benefit to movement initiation, we conclude that home-based neurofeedback for people with PD is a feasible and promising non-pharmacological treatment that warrants further research.

Comparison of Outcomes of Intravenous Dexamethasone Versus Placebo as Adjunct to Local Anaesthetic Brachial Plexus Block for Upper Limb Surgery

Introduction: Dexamethasone has been tested in combination with different local anesthetics with varying degree of results including increase in intensity and duration of block. Objectives: To compare the outcomes of intravenous dexamethasone versus placebo as adjunct to local anesthetic brachial plexus block for upper limb surgery. Study design: Randomized controlled trial Setting: Department of Anesthesia, pain management and intensive care Holy Family Hospital, Rawalpindi. Study duration: 7th November 2019 till 6th May 2020. Materials &amp; Methods: A total of 10 0 patients of either gender aged 18 to 60 years admitted for upper limb surgery were included. Patients with pregnancy, DM, block failure and contraindication to brachial plexus block were excluded. Patients in group A received a block injection with 30ml of 0.5% bupivacaine along with 2ml of intravenous dexamethasone. Group B patients received 30ml of 0.5% bupivacaine for block injection and 2ml of normal saline intravenously. Block success was confirmed using the sensory and motor examination of the upper limb. Block duration was recorded in hours, opioid consumption was recorded in intravenous morphine equivalents in first 24 hours, visual analogue scores for pain on scale of 0-10 at upper limb at rest was recorded at 8 and 24 hours. Results: In our study, duration of local anesthetic brachial plexus block in dexamethasone and placebo group were 16.12 ± 1.33 hrs and 9.77 ± 1.26 hrs respectively with p-value = 0.0001. Opioid consumption in Morphine Equivalents at 24 hrs in local anesthetic brachial plexus block and placebo group were 16.48 ± 2.60 vs 22.68 ± 3.78 with p-value &lt; 0.0001 respectively. Conclusion: This study concluded that intravenous dexamethasone has better outcomes as compared to intravenous saline as adjunct to local anesthetic brachial plexus block for upper limb surgery.

Motor Efficacy of Subcutaneous DIZ102, Intravenous DIZ101 or Intestinal Levodopa/Carbidopa Infusion.

It has been suggested that carbidopa at high blood concentrations may counter the therapeutic effect of levodopa in Parkinson's disease by entering the brain and blocking central levodopa conversion to dopamine. We previously demonstrated equivalent plasma levodopa concentration in patients with Parkinson's disease during 16 h of (1) intravenous carbidopa/levodopa (DIZ101) infusion, (2) subcutaneous carbidopa/levodopa (DIZ102) infusion or (3) intestinal carbidopa/levodopa gel infusion. Plasma levels of carbidopa were however approximately four times higher with DIZ101 and DIZ102 than with LCIG, and higher than those usually observed with oral levodopa/carbidopa. To investigate if high carbidopa blood concentrations obtained with parenteral levodopa/carbidopa (ratio 8:1) counter the effect of levodopa on motor symptoms. Eighteen patients with advanced Parkinson's disease were administered DIZ101, DIZ102, and intestinal levodopa/carbidopa gel for 16 h on different days in randomized order. Video recordings of a subset of the motor examination in the Unified Parkinson's Disease Rating Scale (UPDRS) were evaluated by raters blinded for treatment and time. Motor function was also measured using a wrist-worn device monitoring bradykinesia, dyskinesia, and tremor (Parkinson KinetiGraph). There was no tendency for poorer levodopa effect with DIZ101 or DIZ102 as compared to LCIG. Although DIZ101 or DIZ102 causes approximately four times higher plasma carbidopa levels than LCIG, patients responded equally well to all treatments. The results do not indicate that high plasma carbidopa levels hamper the motor efficacy of levodopa.

Motor Examination of the Brachial Plexus.

Serial physical examination is often required in the evaluation of brachial plexus injuries. (Noland, 2019) A comprehensive evaluation that includes a thorough history, electrodiagnostic evaluation, and imaging studies, in addition to physical examination, can provide valuable information about the location of the lesion, prognosis for recovery, and whether surgical intervention is necessary. After brachial plexus reconstruction, physical examinations are also performed to document clinical improvement and identify any residual issues. The videos included in this clinical examination techniques section demonstrate the muscle strength examination testing for the brachial plexus and offer best practices for documentation.

Detecting the symptoms of Parkinson’s disease with non-standard video

BackgroundNeurodegenerative diseases, such as Parkinson’s disease (PD), necessitate frequent clinical visits and monitoring to identify changes in motor symptoms and provide appropriate care. By applying machine learning techniques to video data, automated video analysis has emerged as a promising approach to track and analyze motor symptoms, which could facilitate more timely intervention. However, existing solutions often rely on specialized equipment and recording procedures, which limits their usability in unstructured settings like the home. In this study, we developed a method to detect PD symptoms from unstructured videos of clinical assessments, without the need for specialized equipment or recording procedures.MethodsTwenty-eight individuals with Parkinson’s disease completed a video-recorded motor examination that included the finger-to-nose and hand pronation-supination tasks. Clinical staff provided ground truth scores for the level of Parkinsonian symptoms present. For each video, we used a pre-existing model called PIXIE to measure the location of several joints on the person’s body and quantify how they were moving. Features derived from the joint angles and trajectories, designed to be robust to recording angle, were then used to train two types of machine-learning classifiers (random forests and support vector machines) to detect the presence of PD symptoms.ResultsThe support vector machine trained on the finger-to-nose task had an F1 score of 0.93 while the random forest trained on the same task yielded an F1 score of 0.85. The support vector machine and random forest trained on the hand pronation-supination task had F1 scores of 0.20 and 0.33, respectively.ConclusionThese results demonstrate the feasibility of developing video analysis tools to track motor symptoms across variable perspectives. These tools do not work equally well for all tasks, however. This technology has the potential to overcome barriers to access for many individuals with degenerative neurological diseases like PD, providing them with a more convenient and timely method to monitor symptom progression, without requiring a structured video recording procedure. Ultimately, more frequent and objective home assessments of motor function could enable more precise telehealth optimization of interventions to improve clinical outcomes inside and outside of the clinic.

Protocol for the Chinese Real-World Evidence for Acute Spinal Cord Injury (ChiRES) study: a prospective, observational, multicentre cohort study of acute spinal cord injury

IntroductionSpinal cord injury (SCI) is a catastrophic event with devastating physical, social and occupational consequences for patients and their families. The number of patients with acute SCI in China continues...

Adolescent Idiopathic Scoliosis Minimum Data Set: Towards Standardization of Data Elements in History and Physical Examination.

Nonoperative care represents a cornerstone of adolescent idiopathic scoliosis (AIS) management, although no consensus exists for a minimal data set. We aimed to determine a consensus in critical data points to obtain during clinical AIS visits. A REDCap-based survey was distributed to Pediatric Orthopedic Society of America (POSNA), Pediatric Spine Study Group (PSSG), and International Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT). Respondents ranked the importance of data points in history, physical examination, and bracing during AIS visits. Results: One hundred eighty-one responses were received (26% response rate), of which 86% were physicians and 14% were allied health professionals. About 80% of respondents worked at pediatric hospitals or pediatric spaces within adult hospitals, and 82% were academic, with the majority (57%) seeing 150+ unique AIS patients annually. Most respondents recommended six-month follow-up for patients under observation (60%) and bracing (54%). Most respondents (75%) considered family history and pain important (69%), with the majority (69%) asking about pain at every visit. Across all time points, Adam's forward bend test, shoulder level, sagittal contour, trunk shift, and curve stiffness were all considered critically important (>60%). At the first visit, scapular prominence, leg lengths, motor and neurological examination, gait, and iliac crest height were also viewed as critical. At the preoperative visit, motor strength and scapular prominence should also be documented. About 39% of respondents use heat sensors to monitor bracing compliance, and average brace wear since the prior visit was considered the most important (85%) compliance data point. This study establishes recommendations for a 19-item minimum data set for clinical AIS evaluation, including history, physical exam, and bracing, to allow for future multicenter registry-based studies.

Radiological and clinical biomarkers in patients with central post stroke pain

Background. Central post-stroke pain (CPSP) occurs following cerebrovascular accidents and is a neuropathic pain syndrome that is characterized by stimulation-independent pain; shooting, burning, or electric shock-like sensation and paresthesia. Multiple pathogenetic theories have been proposed for the CPSP including disinhibition, central sensitization, thalamic changes, and altered function of spinothalamic tract (STT). Investigations such as MRI DTI can help to understand the pathogenesis of CPSP. Objective. To determine the radiological and clinical biomarkers in cases with CPSP. Methods. This case-control study was retrospectively conducted upon 60 persons divided into 20 CPSP cases (group 1), 20 cases with no CPSP (group 2) and 20 healthy controls (group 3). All subjects had Routine MRI and complete neurological examination including “Sensory testing but stroke patients were evaluated by quantitative assessment of neuropathic pain, the National Institutes of Health Stroke Scale (NIHSS), Ashworth scale, Modified Rankin Scale (MRS) and Hamilton depression rating scale (HAM-D scale). Results. Significant differences existed among studied groups as regard motor examination, sensory examination, NIHSS score and Hamilton depression score. A non-significant difference was detected among the groups regarding MRS findings. A significant difference existed between groups 1 and 2, between groups 1 and 3 while no significant difference was detected between groups 2 and 3 for all FA readings and all ADC readings in ipsilateral affected side assessed at internal capsule, midbrain, and pons. No significant difference existed between groups 1 and 2, between groups 1 and 3 and between groups 2 and 3 as regard FA readings and ADC readings in contralateral side assessed at internal capsule, midbrain, and pons. Conclusion. Our study highlighted the significance of white matter tracts (WMT) other than the conventional pain pathways in CPSP and can thus serve as a predictive marker for CPSP onset or a prognostic marker after any drug therapy or neuromodulatory treatment.

Long-term safety, tolerability and efficacy of apomorphine sublingual film in patients with Parkinson’s disease complicated by OFF episodes: a phase 3, open-label study

BackgroundApomorphine sublingual film (SL-APO) is an on-demand treatment for OFF episodes in patients with Parkinson’s disease (PD).ObjectiveTo assess the long-term (≥ 3 years) safety/tolerability and efficacy of SL-APO.MethodsStudy CTH-301 (http://www.clinicaltrials.gov NCT02542696; registered 2015-09-03) was a phase 3, multicentre, open-label study of SL-APO in PD patients with motor fluctuations, comprised of a dose-titration and long-term safety phase. All participants received SL-APO. The primary endpoint was safety/tolerability (treatment-emergent adverse events [TEAEs]) during the long-term safety phase. Efficacy assessments included the Movement Disorder Society-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) part III (motor examination), assessed at weeks 24, 36 and 48 during the first year of the long-term safety phase.Results496 patients were included and 120 (24.2%) completed the long-term safety phase. Mean duration of SL-APO exposure was 294.3 days. TEAEs related to study drug were experienced by 65.3% of patients (most common: nausea [6.0%], stomatitis [1.8%], lip swelling [1.8%], dizziness [1.6%], oral mucosal erythema [1.6%], mouth ulceration [1.6%]). TEAEs leading to study drug withdrawal were experienced by 34.0% of patients (most common: nausea [5.4%], lip swelling [4.5%], mouth ulceration [2.6%], stomatitis [2.3%]). A clinically meaningful reduction in MDS-UPDRS part III score was observed as soon as 15 min following administration of SL-APO, with peak effects observed approximately 30 min post-dose and sustained up to 90 min post-dose; results were consistent over 48 weeks.ConclusionsSL-APO was generally well tolerated and efficacious over the long term as an on-demand treatment for OFF episodes in patients with PD.

Improvement by Medication Less than Expected in Parkinson's Disease: Blinded Evaluation of Levodopa Response.

The latest Movement Disorder Society (MDS) diagnostic criteria require a good and sustained response to medication to get a diagnosis of Parkinson's disease, PD. The aim of this study was to evaluate levodopa response in a group of patients with probable PD, diagnosed by movement disorder specialists. An acute levodopa challenge test (LDCT) was performed after pausing the dopaminergic medication for 6 half-times. The motor part of the Unified Parkinson's Disease Rating Scale was performed in the OFF-state and after LDCT (ON). A good effect was defined as >30% improvement. A video-protocol was used to secure standardized motor examination with blinded assessments of the UPDRS-III OFF and ON. An age-matched group of control subjects (CS) was included but did not go through LDCT. All participants were evaluated with Montreal Cognitive Assessment (MoCA) and Beck's Depression Inventory (BDI). In the statistical analysis, 37 patients were included. Twenty-one patients showed an improvement ≤30%, while 16 patients showed an improvement >30%. LDCT showed an overall mean improvement of 27.3% of motor UPDRS. In 43.2%, there was a discrepancy between the effect seen with the LDCT and the patients' self-perceived medicine evaluation. Patients with PD had a significantly lower MoCA score and more depressive symptoms compared to CS. We showed an acute effect of levodopa using LDCT that was around 30% improvement. While it lends support to the use of this limit in the MDS diagnostic criteria, an acute effect of less than 30% should be considered acceptable in some patients. Our study highlights a discrepancy in the objective measure of medicine effect on motor symptoms and the patient's subjective evaluation.

Efficacy and safety of adjunctive oral therapy in Parkinson’s disease with motor complications: a systematic review and network meta-analysis

BackgroundThe aim of this manuscript is to review the evidence and compare the efficacy and safety of catechol-O-methyltransferase inhibitors (COMT-Is), dopamine receptor agonists (DRAs) and monoamine-oxidase B inhibitors (MAOB-Is) as...