[Scapulothoracic dysbalance in overhead athletes. Causes and therapy strategies]

BACKGROUND

A key element for movement of the arm is the position and motion of the scapula. A stable basis for efficient arm function is only possible if the scapula makes three dimensional movements coordinated with the upper arm.

AIM

This article presents a discussion of causes, diagnosis and therapy options for scapular dyskinesis.

MATERIAL AND METHODS

The article is based on a literature search in the PubMed database and taking own experience into account.

RESULTS

Soft tissue and bony injuries, muscle insufficiency and dysbalance can alter the position and function of the scapula. This pathological position and motion is called scapular dyskinesis. This clinically presents as a prominent medial border and malrotation (lacking external rotation and posterior tilt) of the scapula when raising the arm. The clinical examination includes a visual inspection followed by clinical tests of the scapula at rest and during movement. Specific exercises of the musculature surrounding the scapula and specific techniques for schooling the senses for positioning and movement can harmonize the sequence of movements and restore the dynamic scapular stability.

CONCLUSION

A conservative stepwise and stage-adapted exercise program can be used to treat scapular dyskinesis with good results.

[Electrophysiological control of stereotactic method for treatment of neuromotor dyskinesia and epilepsy]

The results of electrophysiological control of stereotactic method for patient treatment are introduced. There are patients with Parkinsonian disease or some forms of neuromotor dyskinesia and epilepsy. Our practice declared that different diseases can be corrected by electrostimulations or mycrodestruction the same brain deep structures. We can say that the pathophysiological mechanisms of formation these diseases are similar and have some common characters.

[2012: news in neurology]

In 2012, intramuscular midazolam appears as effective as intravenous lorezepam for the first line treatment of convulsive status epilepticus. Perampanel, a new anti-epileptic drug, will be soon available. Two oral treatments are now available for stroke prevention in atrial fibrillation setting. The methylphenidate and the Tai Chi could increase the walk capacity of patients suffering from Parkinson disease. A comprehensive cardiac work-up is essential for some congenital myopathy. A new drug against migraine seems free from vasoconstrictive effect. Antioxidants are harmful in Alzheimer disease. Some oral medication will be available for multiple sclerosis.

[Scapular dyskinesis]

The scapula plays a crucial role for proper shoulder function, serving as a stable base for rotator cuff activation and as a link in the kinetic chain. Joint, ligament or muscular problems near the scapula can lead to malpositions or to an altered movement pattern. This abnormal situation is called "scapular dyskinesis", which appears to be a non-specific response to a painful condition of the shoulder. The clinical examination of the scapula is crucial for every patient presenting a painful shoulder. Systematic observation and testing enable the practitioner to detect subtle static and dynamic abnormalities. Visual evaluation, objective measurements and corrective manoeuvres can evaluate the role of the "scapular dyskinesis" in the shoulder painful condition. The scapular rehabilitation will address muscular retractions and imbalances and restore a good dynamic stability, starting with analytical work, and evolving into more functional and specific exercises.

Deep brain stimulation: current and future clinical applications

Deep brain stimulation (DBS) has developed during the past 20 years as a remarkable treatment option for several different disorders. Advances in technology and surgical techniques have essentially replaced ablative procedures for most of these conditions. Stimulation of the ventralis intermedius nucleus of the thalamus has clearly been shown to markedly improve tremor control in patients with essential tremor and tremor related to Parkinson disease. Symptoms of bradykinesia, tremor, gait disturbance, and rigidity can be significantly improved in patients with Parkinson disease. Because of these improvements, a decrease in medication can be instrumental in reducing the disabling features of dyskinesias in such patients. Primary dystonia has been shown to respond well to DBS of the globus pallidus internus. The success of these procedures has led to application of these techniques to multiple other debilitating conditions such as neuropsychiatric disorders, intractable pain, epilepsy, camptocormia, headache, restless legs syndrome, and Alzheimer disease. The literature analysis was performed using a MEDLINE search from 1980 through 2010 with the term deep brain stimulation, and several double-blind and larger case series were chosen for inclusion in this review. The exact mechanism of DBS is not fully understood. This review summarizes many of the current and potential future clinical applications of this technology.

[Rehabilitation evaluation on post-stroke abnormal movement pattern prevented and treated with acupuncture and rehabilitation]

OBJECTIVE

To explore the impacts of acupuncture and rehabilitation on post-stroke abnormal patterns of limb movement and evaluate them via rehabilitation method.

METHODS

Ninety cases of post-stroke movement disorder were randomly divided into an acupuncture-rehabilitation group, a body acupuncture group and a medication group, 30 cases in each group. In medication group, the conventional medication in neurological department was administered. In acupuncture-rehabilitation group and body acupuncture group, on the basis of the therapy as medication group, scalp acupuncture (such as parietal area and anterior parietal area, etc.), rehabilitation training and traditional body acupuncture [such as Jianyu (LI 15) and Fengshi (GB 31),etc.] were supplemented. The continuous electric stimulation was applied in body acupuncture group. The treatment lasted for 8 weeks. The assessment of clinical efficacy, Fugl-Meyer score, Modified Ashworth scale (MAS), range of motion (ROM) and shoulder pain score were taken as observation indices for rehabilitation evaluation before and after treatment in each group.

RESULTS

The effective rate was 93.1% (27/29) in acupuncture-rehabilitation group, which was superior to 66.7% (20/30) in body acupuncture group and 57.1% (16/28) in control group (both P<0.01) separately. After treatment, Fugl-Meyer score, MAS, ROM of the lower limbs and shoulder joint and shoulder pain score (except medication group) were all remarkably improved as compared with those before treatment in each group (all P<0.01). The improvements in Fugl-Meyer score, MAS, ROM of the upper limbs and shoulder pain score in acupuncture-rehabilitation group were significantly superior to those in body acupuncture group and medication group (P<0.05, P<0.01).

CONCLUSION

Acupuncture and rehabilitation therapy and traditional body acupuncture remarkably improve in post-stroke movement disorder. But acupuncture and rehabilitation therapy is apparently superior to traditional body acupuncture. This therapy can effectively prevent and treat post-stroke abnormal patterns and it is greatly significant in the improvement of survival quality for the patients.

[Painful legs and moving toes syndrome associated with lumbar radiculopathy]

INTRODUCTION

Painful legs and moving toes (PLMT) is a rare syndrome characterized by spontaneous neuropathic pain in the lower limbs associated with peculiar involuntary movements of the toes. It has been associated with a variety of peripheral and central nervous system diseases. Pathophysiology is unclear and treatment approaches remain largely empirical.

CLINICAL CASE

We report a case of a 42-year-old women with typical presentation of PLMT syndrome, associated with lumbar (L5) disc prolapse. Oxcarbazepine gave a partial improvement.

CONCLUSION

Clinical presentations and etiological aspects of the PLMT syndrome are described and pathophysiological mechanisms and therapeutic possibilities discussed.

Globus pallidus stimulation improves both motor and nonmotor aspects of quality of life in advanced Parkinson's disease

Our purpose was to measure the change in quality of life (QoL) following deep brain stimulation of the globus pallidus interna (GPi-DBS) in advanced Parkinson 's disease (PD), and identifies any associations with changes in motor features of the disease. Eleven patients (age range 54-69 years, 2 women) underwent GPi-DBS (4 unilateral, 7 bilateral). Outcome measures included assessment of PD-specific QoL (mean 8 months postsurgery) using the PDQ-39 questionnaire, and standard motor assessments. Off-period UPDRS III motor scores fell by (43 +/- 8)% (mean +/- SEM). Dyskinesia severity was reduced on the abnormal involuntary movement scale by (80 +/- 3)% and UPDRS IVa by (58 +/- 8)%. QoL as assessed by the PDQ39SI improved by (30 +/- 5)%, with significant improvements in mobility, activities of daily living, bodily discomfort, emotional wellbeing, communication, and cognitions subscales. Bilateral and unilateral groups demonstrated equivalent PDQ39SI improvement. QoL improvement was highly correlated with dyskinesia reduction but not reduction in UPDRS score or age at surgery. GPi-DBS markedly improves QoL in advanced PD. The impacts are broad and improve QoL domains not directly affected by the motor symptoms of the disease. Reduced dyskinesia plays a major role in the improvement of QoL in GPi-DBS treated patients.

RGS9-2 negatively modulates L-3,4-dihydroxyphenylalanine-induced dyskinesia in experimental Parkinson's disease

Chronic L-dopa treatment of Parkinson's disease (PD) often leads to debilitating involuntary movements, termed L-dopa-induced dyskinesia (LID), mediated by dopamine (DA) receptors. RGS9-2 is a GTPase accelerating protein that inhibits DA D2 receptor-activated G proteins. Herein, we assess the functional role of RGS9-2 on LID. In monkeys, Western blot analysis of striatal extracts shows that RGS9-2 levels are not altered by MPTP-induced DA denervation and/or chronic L-dopa administration. In MPTP monkeys with LID, striatal RGS9-2 overexpression--achieved by viral vector injection into the striatum--diminishes the involuntary movement intensity without lessening the anti-parkinsonian effects of the D1/D2 receptor agonist L-dopa. In contrasts, in these animals, striatal RGS9-2 overexpression diminishes both the involuntary movement intensity and the anti-parkinsonian effects of the D2/D3 receptor agonist ropinirole. In unilaterally 6-OHDA-lesioned rats with LID, we show that the time course of viral vector-mediated striatal RGS9-2 overexpression parallels the time course of improvement of L-dopa-induced involuntary movements. We also find that unilateral 6-OHDA-lesioned RGS9-/- mice are more susceptible to L-dopa-induced involuntary movements than unilateral 6-OHDA-lesioned RGS9+/+ mice, albeit the rotational behavior--taken as an index of the anti-parkinsonian response--is similar between the two groups of mice. Together, these findings suggest that RGS9-2 plays a pivotal role in LID pathophysiology. However, the findings also suggest that increasing RGS9-2 expression and/or function in PD patients may only be a suitable therapeutic strategy to control involuntary movements induced by nonselective DA agonist such as L-dopa.

Dyskinesien bei Morbus Parkinson - Klinik, Ätiologie, Therapie

Parkinson's disease (PD), a slowly, progressive degenerative disorder of the central nervous system, which affects about ten million people world-wide, is currently treated symptomatically. Current treatment aim i. e. to balance the decreased dopamine turnover in striatal neurons. Chronic exposure to dopaminergic agents, however, supports onset of motor complications and dyskinesia in the long term. Dyskinesia appear mainly as chorea, athetosis, dystonia, stereotypia, ballism or a combination. Sometimes excessive abnormal facial, body and limb movements depend on the overall dosage of dopaminergic substitution. This is why the main therapy is based on reducing the total dosage of dopaminergic substances. Either alternative or additional well-tried substances like apomorphine, amantadine or clozapine are used. New possibilities in treatment emerge from substances like sarizotan, istradefylline, fipampezol or talampanel. Even so disability and reduced quality of life in PD patients and their caregivers may exist. This survey describes the major clinical features, aetiology and demographics of treatment-associated dyskinesia in PD.

Laryngeal dyskinesia: an under-recognized condition

OBJECTIVE

To perform a review of the epidemiology, pathogenesis, clinical presentation, diagnosis and management of laryngeal dyskinesia.

METHODS

A search of the Medline database from 1966 to 2003 was performed. A manual search was performed of the references of each article.

RESULTS

Laryngeal dyskinesia is a respiratory condition characterized by abnormal vocal cord adduction and airflow limitation at the level of the larynx in the absence of evidence of local organic disease. It typically presents to the ED as wheeze, stridor or apparent upper airway obstruction. It occurs across a wide age range, is more common in females, and is typically associated with a range of underlying psychopathologies. Diagnosis is often delayed and unnecessary emergency treatment such as intubation and tracheostomy is not uncommon. Patients are commonly on high-dose steroids and are frequent users of the health-care system, often over prolonged periods. There are multiple diagnostic features on history and examination, and flexible nasendoscopy of the vocal cords in the ED can be used to confirm the diagnosis. Treatment options in the ED include sedation and use of continuous positive airway pressure. Long-term treatment involves a multidisciplinary approach involving respiratory physicians/ear, nose and throat surgeons, speech therapy and psychiatry.

CONCLUSION

Laryngeal dyskinesia remains an under-appreciated cause of respiratory presentations to the ED. Emergency physicians are ideally placed to make the diagnosis and initiate appropriate referral for specific therapies that have a high level of success.

Stimulation of subthalamic fibre tracts reduces dyskinesias in STN-DBS

Rarely, the postoperative management of patients with subthalamic deep brain stimulation (STN-DBS) is complicated by pharmacologically intractable dyskinesias. Here we report that in three of these patients additional stimulation of a proximal contact located within the subthalamic white matter may lead to a significant reduction of dyskinesias associated with STN-DBS. We propose that pallidofugal fiber tracts play a major role in the etiopathology of dyskinesias and their blockade through DBS may explain our observations.

Four oral motor disorders: bruxism, dystonia, dyskinesia and drug-induced dystonic extrapyramidal reactions

This article reviews four of the involuntary hyperkinetic motor disorders that affect the orofacial region: bruxism, orofacial dystonia, oromandibular dyskinesia, and medication-induced extrapyramidal syndrome-dystonic reactions. It discusses and contrasts the clinical features and management strategies for spontaneous, primary, and drug-induced motor disorders in the orofacial region. The article provides a list of medications that have been reported to cause drug-related extrapyramidal motor activity, and discusses briefly the genetic and traumatic events that are associated with spontaneous dystonia. Finally, it presents an approach for management of the orofacial motor disorders. The contraindications, side effects, and usual approach for medications and injections are covered. An overview of the indications, contraindications, and complications of using botulinum toxin as a therapeutic modality is discussed briefly.

[Neurosurgical treatment in childhood dystonias and dyskinesias]

AIM

To present the post-surgery clinical results of deep brain stimulation of the internal globus pallidus (GPi) in a group of paediatric patients with primary and secondary dystonic-dyskinetic syndrome.

PATIENTS AND METHODS

Between November 1996 and May 2006, 121 patients were submitted to interventions with bilateral deep brain stimulation of the GPi, 58 of whom were children (age range: 5-16 years); 35 were cases of primary dystonia, of which 17 were carriers of the DYT1 mutation and 10 were not. A further 8 cases were myoclonic dystonias, 3 of whom presented the DYT11 mutation. With regard to the secondary dystonias, 4 were carriers of PKAN (pantothenate kinase-associated neurodegeneration) syndrome and 9 were cases of post-anoxic encephalopathies.

RESULTS

Percentage improvements were as follows: in the case of DYT1+ primary dystonias, 80% at one year maintained at 3 years; in cases of DYT1-, 70% at one year maintained at 3 years, and in the myoclonic dystonias, 50% at one year and 85% at 3 years. In the group of patients with secondary dystonias due to post-anoxic encephalopathies, we found an improvement of 30% at one year and 40% at 3 years; in the group with PKAN syndrome, the figures were 60% at one year and 50% at two years.

CONCLUSIONS

Treatment involving bilateral deep brain stimulation of the GPi nuclei in childhood cases of generalised dystonias is highly effective, the best prognoses being those offered by the group with primary dystonias and especially those related to the DYT1 mutation. Treatment also proved to be effective in the case of secondary dystonias, although with lower degrees of improvement.

Bilateral effects of unilateral subthalamic nucleus deep brain stimulation in advanced Parkinson's disease

To investigate the bilateral effects of unilateral subthalamic nucleus deep brain stimulation (STN-DBS), we prospectively studied 9 consecutive advanced Parkinson's disease (PD) patients (2 men and 7 women) who underwent unilateral STN-DBS. Patients were evaluated preoperatively and at 3 and 6 months postoperatively with and without dopaminergic medications ('on' and 'off' medication, respectively). Postoperatively, patients were assessed with and without stimulation. We found that, when compared with baseline, the 'off' medication scores of the Unified Parkinson's Disease Rating Scale motor part (UPDRS III) and activities of daily living (UPDRS II) were improved by 37% (p = 0.028) and 50% (p = 0.046) at 6 months after surgery, respectively. Stimulation while 'off' medication improved the total UPDRS score by 42% (p = 0.028) at 6 months. At 6 months after surgery, the subscore of UPDRS III of body parts contralateral to the DBS implantation had improved by 48% (p = 0.028), and the ipsilateral subscore of UPDRS III and the axial subscore of UPDRS III had improved by 20% (p = 0.027) and 39% (p = 0.028), respectively. Daily dosage of levodopa was reduced by 15% at 6 months. No patient exhibited permanent side effects. These findings indicate that unilateral STN-DBS may be a reasonable surgical procedure for selected PD patients who have markedly asymmetric parkinsonism.

A randomized trial of deep-brain stimulation for Parkinson's disease

BACKGROUND

Neurostimulation of the subthalamic nucleus reduces levodopa-related motor complications in advanced Parkinson's disease. We compared this treatment plus medication with medical management.

METHODS

In this randomized-pairs trial, we enrolled 156 patients with advanced Parkinson's disease and severe motor symptoms. The primary end points were the changes from baseline to six months in the quality of life, as assessed by the Parkinson's Disease Questionnaire (PDQ-39), and the severity of symptoms without medication, according to the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III).

RESULTS

Pairwise comparisons showed that neurostimulation, as compared with medication alone, caused greater improvements from baseline to six months in the PDQ-39 (50 of 78 pairs, P=0.02) and the UPDRS-III (55 of 78, P<0.001), with mean improvements of 9.5 and 19.6 points, respectively. Neurostimulation resulted in improvements of 24 to 38 percent in the PDQ-39 subscales for mobility, activities of daily living, emotional well-being, stigma, and bodily discomfort. Serious adverse events were more common with neurostimulation than with medication alone (13 percent vs. 4 percent, P<0.04) and included a fatal intracerebral hemorrhage. The overall frequency of adverse events was higher in the medication group (64 percent vs. 50 percent, P=0.08).

CONCLUSIONS

In this six-month study of patients under 75 years of age with severe motor complications of Parkinson's disease, neurostimulation of the subthalamic nucleus was more effective than medical management alone. (ClinicalTrials.gov number, NCT00196911 [ClinicalTrials.gov].).

End of day dyskinesia in advanced Parkinson's disease can be eliminated by bilateral subthalamic nucleus or globus pallidus deep brain stimulation

We report the therapeutic effects of deep brain stimulation (DBS) in 2 patients with Parkinson's disease (PD) with severe end of dose dyskinesia that was resistant to medical therapy. In both patients, severe, end of day ballistic dyskinesias occurred when the last levodopa dose of the day was wearing off. Globus pallidus (GPi) DBS in 1 case and subthalamic (STN) DBS in the second case produced full resolution of end of day dyskinesia.

Deep Brain Stimulation of the Internal Segment of the Globus Pallidus in Delayed Runaway Dyskinesia

BACKGROUND

Dyskinesias that occur during a period without medication after embryonic cell transplantation have been commonly reported in double-blind trials; however, to date, they have not been reported in the few patients who participated in open-label pilot studies.

DESIGN

Single case observation with preoperative and postoperative data, and intraoperative single-cell physiology.

PATIENT

A patient who underwent embryonic cell transplantation in 1993 as part of the University of South Florida open-label study was referred for evaluation of intractable dyskinesia of the right arm. The dyskinesia was present during evaluation of the patient after a 12-hour period without medication and was clinically disabling. It was manifested as a severe groping movement of the hand. Intraoperative physiologic evaluation revealed decreased firing rates in the internal segment of the globus pallidus.

RESULTS

Deep brain stimulation of the internal segment of the globus pallidus resulted in resolution of the dyskinesia.

CONCLUSION

This case highlights the delayed development of runaway dyskinesia after a period without medication as an important potential long-term adverse effect of embryonic cell transplantation in patients with Parkinson disease.

Practice Parameter: Treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): [RETIRED]

Objective: To make evidence-based treatment recommendations for the medical and surgical treatment of patients with Parkinson disease (PD) with levodopa-induced motor fluctuations and dyskinesia. To that end, five questions were addressed. 1. Which medications reduce off time? 2. What is the relative efficacy of medications in reducing off time? 3. Which medications reduce dyskinesia? 4. Does deep brain stimulation (DBS) of the subthalamic nucleus (STN), globus pallidus interna (GPi), or ventral intermediate (VIM) nucleus of the thalamus reduce off time, dyskinesia, and antiparkinsonian medication usage and improve motor function? 5. Which factors predict improvement after DBS?

Methods: A 10-member committee including movement disorder specialists and general neurologists evaluated the available evidence based on a structured literature review including MEDLINE, EMBASE, and Ovid databases from 1965 through June 2004.

Results, Conclusions, and Recommendations: 1. Entacapone and rasagiline should be offered to reduce off time (Level A). Pergolide, pramipexole, ropinirole, and tolcapone should be considered to reduce off time (Level B). Apomorphine, cabergoline, and selegiline may be considered to reduce off time (Level C). 2. The available evidence does not establish superiority of one medicine over another in reducing off time (Level B). Sustained release carbidopa/levodopa and bromocriptine may be disregarded to reduce off time (Level C). 3. Amantadine may be considered to reduce dyskinesia (Level C). 4. Deep brain stimulation of the STN may be considered to improve motor function and reduce off time, dyskinesia, and medication usage (Level C). There is insufficient evidence to support or refute the efficacy of DBS of the GPi or VIM nucleus of the thalamus in reducing off time, dyskinesia, or medication usage, or to improve motor function. 5. Preoperative response to levodopa predicts better outcome after DBS of the STN (Level B).

Chronic stimulation of the subthalamic nucleus increases daily on-time without dyskinesia in advanced Parkinson's disease

We assessed the efficacy of chronic stimulation of the subthalamic nucleus (STN-DBS) in 20 patients with Parkinson's disease (PD) by means of clinical assessments and patient diaries 12 months after surgery. STN-DBS reduced the UPDRS part III off-medication score by 33%, and successively improved complete daily on-time without dyskinesia at 12 months significantly. In conclusion, our study demonstrates the efficacy of chronic STN-DBS on motor features in a selected population of advanced PD patients. In addition to clinical assessments, patients' diaries serve as an essential tool to evaluate the functional motor status after STN-DBS.

Sensory timing cues improve akinesia of grasping movements in Parkinson's disease: A comparison to the effects of subthalamic nucleus stimulation

Five parkinsonian subjects with chronic bilateral stimulation of the subthalamic nucleus and five sex- and age-matched healthy controls grasped, lifted, and held an instrumented object. The grip-lift task was either performed at self-determined speed or in response to an auditory cuing signal. Parkinsonian subjects performed the task with subthalamic nucleus stimulation switched ON and OFF. In Parkinson's disease, stimulation of the subthalamic nucleus and the presentation of auditory timing cues improved akinesia of both the grasp and lift components of the task. The finding that auditory timing cues improve akinesia in the absence of subthalamic nucleus stimulation suggests that the basal ganglia are less involved in the control of movements made in response to environmental cues. However, subthalamic nucleus stimulation caused parkinsonian subjects to apply excessive grip forces, regardless of whether the movement was made under self-determined or externally guided speed conditions. This implies that subthalamic nucleus stimulation produces a generalized upregulation in the gain of all components of a movement without the subtlety of focused control that is required to normalize performance.