Establishing apomorphine treatment in Thailand: understanding the challenges and opportunities of Parkinson's disease management in developing countries

INTRODUCTION

The increasing global burden of Parkinson's disease (PD) poses a particular challenge for developing countries, such as Thailand, when delivering care to a geographically diverse populace with limited resources, often compounded by a lack of expertise in the use of certain PD medications, such as device-aided therapies (DAT).

AREAS COVERED

A panel of local, regional, and international PD experts convened to review the unmet needs of PD in Thailand and share insights into effective delivery of DAT, focusing on experience with apomorphine infusion. Despite its proven efficacy and safety, implementation of apomorphine infusion as a new option was not straightforward. This has prompted a range of health-care professional and patient-focused initiatives, led by the Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders in Bangkok, to help establish a more coordinated approach to PD management throughout the country and ensure patients have access to suitable treatments.

EXPERT OPINION

Overcoming the challenges of education, proficiency, resource capacity and standard of care for PD patients in developing countries requires a coordinated effort both nationally and beyond. The best practices identified in Thailand following the introduction of apomorphine infusion might be helpful for other countries when implementing similar programs.

COVID-19: An Early Review of Its Global Impact and Considerations for Parkinson's Disease Patient Care

While many infectious disorders are unknown to most neurologists, COVID-19 is very different. It has impacted neurologists and other health care workers, not only in our professional lives but also through the fear and panic within our own families, colleagues, patients and their families, and even in the wider public. COVID-19 affects all sorts of individuals, but the elderly with underlying chronic conditions are particularly at risk of severe disease, or even death. Parkinson's disease (PD) shares a common profile as an age-dependent degenerative disorder, frequently associated with comorbidities, particularly cardiovascular diseases, so PD patients will almost certainly fall into the high-risk group. Therefore, the aim of this review is to explore the risk of COVID-19 in PD based on the susceptibility to severe disease, its impact on PD disease severity, potential long-term sequelae, and difficulties of PD management during this outbreak, where neurologists face various challenges on how we can maintain effective care for PD patients without exposing them, or ourselves, to the risk of infection. It is less than six months since the identification of the original COVID-19 case on New Year's Eve 2019, so it is still too early to fully understand the natural history of COVID-19 and the evidence on COVID-19-related PD is scant. Though the possibilities presented are speculative, they are theory-based, and supported by prior evidence from other neurotrophic viruses closely related to SARS-CoV-2. Neurologists should be on high alert and vigilant for potential acute and chronic complications when encountering PD patients who are suspected of having COVID-19.

Delivering patient-centered care in Parkinson's disease: Challenges and consensus from an international panel

An international panel of movement disorders specialists explored the views and perceptions of people with Parkinson's disease (PD) about their condition and its treatment, including the potential mismatch between the clinician's view of the patient's condition and their own view of what aspects of the disease most affect their daily lives. The initiative was focused on Asian countries, so participants comprised experts in the management of PD from key centers in Asia, with additional insight provided by European and the North American movement disorders experts. Analysis of peer-reviewed publications on patient perceptions of PD and the factors that they consider important to their wellbeing identified several contributing factors to the mismatch of views, including gaps in knowledge of PD and its treatment, an understanding of the clinical heterogeneity of PD, and the importance of a multidisciplinary approach to patient care. The faculty proposed options to bridge these gaps to ensure that PD patients receive the personalized treatment they need to achieve the best possible outcomes. It was considered essential to improve patient knowledge about PD and its treatment, as well as increasing the awareness of clinicians of PD heterogeneity in presentation and treatment response. A multidisciplinary and shared-care approach to PD was needed alongside the use of patient-centered outcome measures in clinical trials and clinical practice to better capture the patient experience and improve the delivery of individualized therapy.

More than hemifacial spasm? A case of unilateral facial spasms with systematic review of red flags

Unilateral facial spasms (UFS) are frequently caused by hemifacial spasm (HFS), a disorder that usually results from vascular loop compression at the root exit zone of the facial nerve. However, UFS can also be a manifestation of other conditions, including brainstem tumours or demyelination, post-Bell's synkinesis, lesions of the facial nerve in the Faloppio canal and the parotid gland, dystonia, epilepsy, psychogenic conditions, tics and hemimasticatory spasm. In this report, we present a case of UFS, not due to HFS, highlighting clinical red flags for an alternative diagnosis. In addition, a systematic review was conducted to provide a comprehensive summary of UFS differential diagnoses with a list of red flags to assist neurologists in the evaluation of patients with UFS.

Subthalamic deep brain stimulation aggravates speech problems in Parkinson's disease: Objective and subjective analysis of the influence of stimulation frequency and electrode contact location

BACKGROUND

Speech disorders, including stuttering and hypophonia, have been reported in patients with Parkinson's disease (PD) after subthalamic deep brain stimulation (STN-DBS).

OBJECTIVE

To evaluate the effect of stimulation frequency or electrode contact location on speech disorders in PD patients with STN-DBS.

METHOD

In this case-controlled study, we enrolled 50 PD patients with, and 100 PD patients without STN-DBS to compare their vocal intensities, measured by a sound pressure meter, and perceptual speech ratings, obtained from the speech sections of the United Parkinson's Disease Rating Scale (UPDRS) and subjective ratings regarding the impediment of functional communication by stuttering. For patients with STN-DBS, comparisons were made between high-frequency (HFS; 130 Hz), low-frequency (LFS; 80 Hz), and off-stimulation. We also evaluated the effect of electrode contact locations on speech function.

RESULTS

Patients with STN-DBS had decreased vocal intensities and UPDRS scores compared to those without (p < 0.05). Vocal intensity was significantly lower during HFS than during LFS and off-stimulation (both, p < 0.05). Stuttering impeded STN-DBS patients' communication to greater extent than for those without (p < 0.001). Vocal intensity was lower when active contacts were in the dorsal zone compared to those in the ventral zone (p < 0.05). Only STN-DBS treatment was a predictive factor for low vocal intensity (OR = 9.53, p = 0.04).

CONCLUSION

High-frequency STN-DBS with dorsal zone contacts can aggravate certain speech problems in PD patients. Therefore, it is important to balance between motor control and speech impairments in these patients.

Posturographic abnormalities in ambulatory atypical parkinsonian disorders: Differentiating characteristics

BACKGROUND

Postural instability is a common complaint in patients with Parkinson's disease (PD), multiple system atrophy (MSA) and progressive supranuclear palsy (PSP). However, objective evaluation to identify posturographic characteristics to enable clinical differentiation is limited.

METHOD

Postural sway abnormalities in 35 atypical parkinsonian patients (19 PSP, 16 MSA), 35 matched PD patients, and healthy subjects were assessed under static posturography with eyes-open (EO) and eyes-closed (EC).

RESULTS

With EO, MSA patients showed a significantly greater mean ML sway than PD patients (p = 0.03), but with EC even more parameters were significantly different, including mean sway in both ML (p = 0.02) and AP directions (p = 0.01), sway area (p = 0.001), and sway path length (p = 0.003). While differences between MSA and PD were seen in both ML and AP directions, significant differences between PD and PSP were limited to greater mean ML sway (p = 0.01) with EO, greater mean (p = 0.002) and maximal AP sway (p = 0.02) amongst PSP patient with EC. Moderate and significant correlation was demonstrated between HY stage and mean AP sway amongst APD patients (r = 0.56, p < 0.01) and in PSP patients (r = 0.62, p < 0.01).

CONCLUSION

Our study identifies a number of objective sway measures assessed with EC that are potentially useful for clinical differentiation between APDs and PD. In comparison to PD, MSA showed greater sway area and a mean sway distance in both AP and ML directions, while the difference was limited to AP in PSP. Significant correlation between HY stage and sway parameters further supports postural sway as a potential disease progression marker in APDs.

How to spot ocular abnormalities in progressive supranuclear palsy? A practical review

Background

For parkinsonian disorders, progressive supranuclear palsy (PSP) continues to be significant for differential diagnosis. PSP presents a range of ocular abnormalities that have been suggested as optional tools for its early detection, apart from the principal characteristic of postural unsteadiness. Nonetheless, such symptoms may be difficult to identify, particularly during the early onset stage of the disorder. It may also be problematic to recognize these symptoms for general practitioners who lack the required experience or physicians who are not specifically educated and proficient in ophthalmology or neurology.

Main body

Thus, here, a methodical evaluation was carried out to identify seven oculomotor abnormalities occurring in PSP, comprising square wave jerks, the speed and range of saccades (slow saccades and vertical supranuclear gaze palsy), ‘round the houses’ sign, decreased blink rate, blepharospasm, and apraxia of eyelid opening. Inspections were conducted using direct visual observation. An approach to distinguish these signs during a bedside examination was also established. When presenting in a patient with parkinsonism or dementia, the existence of such ocular abnormalities could increase the risk of PSP. For the distinction between PSP and other parkinsonian disorders, these signs hold significant value for physicians.

Conclusion

The authors urge all concerned physicians to check for such abnormalities with the naked eye in patients with parkinsonism. This method has advantages, including ease of application, reduced time-consumption, and requirement of minimal resources. It will also help physicians to conduct efficient diagnoses since many patients with PSP could intially present with ocular symptoms in busy outpatient clinics.

Electronic supplementary material

The online version of this article (10.1186/s40035-019-0160-1) contains supplementary material, which is available to authorized users.

Objective Monitoring of Driving Behavior in Parkinson's Disease: The Utility of the Chula Parkinson Car®

INTRODUCTION

Driving competency is important to evaluate among individuals with Parkinson's disease (PD). Driving in natural situations is the preferred assessment method; thus, we used a naturalistic driving environment to identify driving competency among individuals with PD in comparison to healthy age-matched controls.

METHODS

Based on a power analysis, we recruited 20 participants (10 with PD and 10 healthy age-matched controls). Each participant completed 3 tasks while driving the ChulaPD car, a 4-door sedan installed with computerized monitoring systems. The tasks were forward and backward vehicle movement, reversing into a parking space, and parking parallel to a sidewalk. Trip start and end times, vehicle speed, and acceleration and deceleration times were logged using steering wheel motion, location parking sensors, and dashboard cameras and compared between groups.

RESULTS

Age, gender, possession of a driver's license, present driving conditions, Thai Mini-Mental State Examination score, and driving experience did not significantly differ between groups. However, the PD group took longer to complete the driving tests (p = 0.002), had slower vehicle speeds (p = 0.002), longer brake times (p = 0.007), and decreased brake pressure ability (p = 0.009). Under normalized conditions, the ratio of failed driver's license tests was also higher among the PD group than in the control group (70 vs. 10%, p = 0.006).

CONCLUSIONS

Individuals with PD had less-than-adequate driving ability based on our naturalistic setting. Our assessment method may be useful in other populations with chronic illnesses or for older adults. We discuss how naturalistic assessments could become the standard for evaluating driving ability in Thailand and elsewhere.

Association between Sleep Disturbances and Daytime Somnolence in Parkinson's Disease

BACKGROUND

Sleep disturbance is a common problem among patients with Parkinson's disease (PD).

OBJECTIVES

To investigate the prevalence of daytime somnolence and night-time sleep disturbances; to characterise the night-time sleep disturbance in patients with daytime somnolence; and to determine the correlation between daytime somnolence and night-time sleep disturbances.

METHODS

One hundred and sixty patients with PD were included in the study. Each patient completed the Thai version of the Epworth Sleepiness Scale (ESS) questionnaire to evaluate excessive daytime sleepiness (EDS), and the PD Sleep Scale version-2 (PDSS-2) questionnaire to evaluate night-time sleep disturbance. Subjective sleep information and details about the presence or absence of sleep attack (SA) were also obtained from the patients.

RESULTS

The types of daytime somnolence found in this study were EDS, SA, and combination of EDS and SA (EDS + SA) with the prevalence rates of 22.5, 3.1 and 6.3%, respectively. The prevalence of night-time sleep disturbance was 46.9%. The most common nocturnal disturbance (82.5%) was "get up at night to pass urine". There was a significant positive correlation between the ESS score and PDSS-2 total score with a correlation coefficient of 0.16 (p = 0.043). Patients with "EDS + SA" were the most affected by nocturnal disturbances, as they represented the largest group among those patients with night-time disturbances and had the highest PDSS-2 total score (p < 0.05).

CONCLUSION

There are differences in nocturnal sleep disturbances among PD patients with different types of daytime somnolence. The significant positive correlation between the ESS and the PDSS-2 total scores suggests that night-time sleep disturbance may influence daytime somnolence.

Exploring bedside clinical features of parkinsonism: A focus on differential diagnosis

The proper diagnosis of parkinsonian disorders usually involves three steps: identifying core features of parkinsonism; excluding other causes; and collating supportive evidence based on clinical signs or investigations. While the recognition of cardinal parkinsonian features is usually straightforward, the appreciation of clinical features suggestive of specific parkinsonian disorders can be challenging, and often requires greater experience and skills. In this review, we outline the clinical features that are relevant to the differential diagnosis of common neurodegenerative parkinsonian disorders, including Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, and corticobasal degeneration. We aim to make this process relatable to clinicians-in-practice, therefore, have categorised the list of clinical features into groups according to the typical sequence on how clinicians would elicit them during the examination, starting with observation of facial expression and clinical signs of the face, spotting eye movement abnormalities, examination of tremors and jerky limb movements, and finally, examination of posture and gait dysfunction. This review is not intended to be comprehensive. Rather, we have focused on the most common clinical signs that are potentially key to making the correct diagnosis and those that do not require special skills or training for interpretation. Evidence is also provided, where available, such as diagnostic criteria, consensus statements, clinicopathological studies or large multi-centre registries. Pitfalls are also discussed when relevant to the diagnosis. While no clinical signs are pathognomonic for certain parkinsonian disorders, certain clinical clues may assist in narrowing a differential diagnosis and tailoring focused investigations for the individual patient.

Red flags phenotyping: A systematic review on clinical features in atypical parkinsonian disorders

To establish a clinical diagnosis of a parkinsonian disorder, physicians rely on their ability to identify relevant red flags, in addition to cardinal features, to support or refute their working diagnosis in an individual patient. The term 'red flag', was originally coined in 1989 to define the presence of non-cardinal features that may raise a suspicion of multiple system atrophy (MSA), or at least suggest alternative diagnosis to Parkinson's disease (PD). Since then, the term 'red flag', has been consistently used in the literature to denote the clinical history or signs that may signal to physicians the possibility of an atypical parkinsonian disorder (APD). While most red flags were originally based on expert opinion, many have gained acceptance and are now included in validated clinical diagnostic criteria of PD and APDs. The clinical appreciation of red flags, in conjunction with standard criteria, may result in a more accurate and earlier diagnosis compared to standard criteria alone. However, red flags can be clinical signs that are non-neurological, making the systematic assessment for them a real challenge in clinical practice. Here, we have conducted a systematic review to identify red flags and their clinical evidence in the differential diagnosis of common degenerative parkinsonism, including PD, MSA, progressive supranuclear palsy (PSP), corticobasal degeneration (CBD), and dementia with Lewy body (DLB). Increasing awareness and appropriate use of red flags in clinical practice may benefit physicians in the diagnosis and management of their patients with parkinsonism.

Exploring Bedroom Usability and Accessibility in Parkinson's Disease (PD): The Utility of a PD Home Safety Questionnaire and Implications for Adaptations

Background

Although bedrooms are identified as a major location for accidents among Parkinson’s disease (PD) patients, there are no studies that specifically evaluate the bedroom environments of PD patients.

Objective

To examine the physical bedroom environment of patients with PD by generating a home safety questionnaire to rate bedroom accessibility and usability specifically for PD patients, and piloting it in a small set of PD patients, to identify environmental barriers and recommend adaptations to reduce accident risks.

Methods

Questionnaire development was based on the concept of Personal (P)-Environmental (E) fit. The P component covers five clinical domains that contribute to a patients’ current state of health, including PD-related motor symptoms, PD-related non-motor symptoms, gait and balance impairments, comorbidities, and limitations on specific activities. The E component focuses on both indoor (bedroom, bathroom, living room, stairs, and kitchen), and outdoor (outdoor area and entrance) areas within a home where PD patients commonly get injured. Total score for the whole questionnaire is 171. A higher score indicates more P-E problems.

Results

Comprehension of questions was tested for content validity with an item-objective congruence index of above 0.6 for all items. High internal consistency (reliability) was confirmed by Cronbach’s alpha coefficient of 0.828 (r). The pilot in five PD patients gave a mean total score of 48.2 ± 7.29 with a mean score on personal and environmental components of 16.8 ± 5.12 and 31.4 ± 4.51, respectively.

Conclusion

This PD home safety questionnaire is a valid and reliable instrument for examining P-E problems by a multidisciplinary team during their home visits. More studies, involving a large number of PD patients, are needed to establish its utility as a screening instrument in PD patients to assess for home adaptations.

Capturing nighttime symptoms in Parkinson disease: Technical development and experimental verification of inertial sensors for nocturnal hypokinesia

Although nocturnal hypokinesia represents one of the most common nocturnal disabilities in Parkinson disease (PD), it is often a neglected problem in daily clinical practice. We have developed a portable ambulatory motion recorder (the NIGHT-Recorder), which consists of 16-bit triaxial integrated microelectromechanical system inertial sensors that are specifically designed to measure movements, register the position of the body with respect to gravity, and provide information on rotations on the longitudinal axis while lying in bed. The signal processing uses the forward derivative method to identify rolling over and getting out of bed as primary indicators. The prototype was tested on six PD pairs to measure their movements for one night. Using predetermined definitions, 134 movements were captured consisting of rolling over 115 times and getting out of bed 19 times. Patients with PD rolled over significantly fewer times than their spouses (p = 0.03), and the position change was significantly smaller in patients with PD (p = 0.03). Patients with PD rolled over at a significantly slower speed (p = 0.03) and acceleration (p = 0.03) than their spouses. In contrast, patients with PD got out of bed significantly more often than their spouses (p = 0.02). It is technically feasible to develop an easy-to-use, portable, and accurate device that can assist physicians in the assessment of nocturnal movements of patients with PD.

Can therapeutic Thai massage improve upper limb muscle strength in Parkinson's disease? An objective randomized-controlled trial

Muscle weakness is a frequent complaint amongst Parkinson's disease (PD) patients. However, evidence-based therapeutic options for this symptom are limited. We objectively measure the efficacy of therapeutic Thai massage (TTM) on upper limb muscle strength, using an isokinetic dynamometer. A total of 60 PD patients with muscle weakness that is not related to their ‘off’ periods or other neurological causes were equally randomized to TTM intervention (n = 30), consisting of six TTM sessions over a 3-week period, or standard medical care (no intervention, n = 30). Primary outcomes included peak extension and flexion torques. Scale-based outcomes, including Unified Parkinson's Disease Rating Scale (UPDRS) and visual analogue scale for pain (VAS) were also performed. From baseline to end of treatment, patients in the intervention group showed significant improvement on primary objective outcomes, including peak flexion torque (F = 30.613, p < .001) and peak extension torque (F = 35.569, p < .001) and time to maximal flexion speed (F = 14.216, p = .001). Scale-based assessments mirrored improvements in the objective outcomes with a significant improvement from baseline to end of treatment of the UPDRS-bradykinesia of a more affected upper limb (F = 9.239, p = .005), and VAS (F = 69.864, p < .001) following the TTM intervention, compared to the control group. No patients reported adverse events in association with TTM. Our findings provide objective evidence that TTM used in combination with standard medical therapies is effective in improving upper limb muscle strength in patients with PD. Further studies are needed to determine the efficacy of TTM on other motor and non-motor symptoms in PD.

Ixcellence Network®: an international educational network to improve current practice in the management of cervical dystonia or spastic paresis by botulinum toxin injection

Botulinum toxin is a well-established treatment for a number of conditions involving muscle hyperactivity, such as focal dystonia and spastic paresis. However, current injection practice is not standardized and there is a clear need for structured training. An international group of experts in the management of patients with cervical dystonia (CD) and spastic paresis created a steering committee (SC). For each therapeutic area, the SC developed a core slide set on best practice, based on the literature. International sites of expertise were identified for training and courses were designed to include lectures and casebased learning. Where possible, courses received accreditation from the European Union of Medical Specialists (UEMS). Each course was peer reviewed by the SC, the UEMS accreditation board and the attendees themselves (through evaluation questionnaires). Attendees' feedback was shared with the SC and the trainers to tailor future training sessions. From the program launch in 2012 to December 2014, 328 physicians from 34 countries were trained in a total of 58 courses; 67% of the courses focused on spastic paresis and 33% on CD. Of the 225 (69%) physicians who completed feedback forms, 95% rated their course as 'above average/excellent' in meeting the preset learning objectives. Most (90%) physicians declared that attending a course would lead them to change their practice. The development of the 'Ixcellence Network' for continuous medical education in the fields of spastic paresis and CD has provided a novel and interactive way of training physicians with previous experience in botulinum toxin injection.

Symptomatic orthostatic hypotension in Parkinson's disease patients: Prevalence, associated factors and its impact on balance confidence

BACKGROUND

Orthostatic hypotension (OH) is a commonly reported sign of the cardiovascular autonomic dysfunctions associated with Parkinson's disease (PD). Patients might suffer from a variety of the clinical symptoms of OH, including dizziness, lightheadedness, or problems with vision and fatigue.

OBJECTIVES

To determine the prevalence of, and factors associated with, symptomatic orthostatic hypotension (OH) in Parkinson's disease (PD) and to identify any relationships between the clinical symptoms of OH and balance confidence in this patient population.

METHODS

Symptomatic OH was defined as a systolic or diastolic BP fall of ≥20 or ≥10mmHg respectively, within 3min of standing and an Orthostatic Hypotension Questionnaire (OHQ) score of more than zero. Factors related to symptomatic OH were identified from a multivariate logistic regression analysis. Pearson's correlation test was used to reveal any relationships between the clinical symptoms of OH and a patient's confidence in their ability to balance, assessed using the Activities-specific Balance Confidence (ABC) scale.

RESULTS

100 Thai PD patients were consecutively recruited into this study. The prevalence of symptomatic OH was 18%, asymptomatic OH was 4%, while 78% were patients without OH. Factors associated with symptomatic OH were age (OR, 95%CI: 1.06, 1.003-1.115, p=0.038) and hypertension (OR, 95%CI: 6.16, 1.171-32.440, p=0.032). A significant and negative correlation (r=-0.229, p=0.022) between OHQ composite scores and item 3 of the ABC scale (picking up slippers from floor), one of the movements in a vertical orientation, was found.

CONCLUSION

Elderly PD patients and with a co-morbidity of essential hypertension should be closely evaluated for the presence of symptomatic OH. In addition, they should be advised to change positions slowly, especially those in a vertical orientation.

Tremor's glove-an innovative electrical muscle stimulation therapy for intractable tremor in Parkinson's disease: A randomized sham-controlled trial

BACKGROUND

Medically refractory resting tremor is a debilitating symptom of Parkinson's disease (PD) patients. In our pilot study, modulation of peripheral reflex mechanism by electrical muscle stimulation (EMS) temporarily suppressed tremor.

OBJECTIVES

To investigate the efficacy of EMS, delivered using Tremor's glove, as a treatment of resting hand tremor.

PATIENTS AND METHODS

Thirty PD patients with medically refractory resting tremor were randomly allocated to a Tremor's glove group (n=15) or a sham glove group (n=15). Gloves were placed on the most tremulous hand for 30min per testing session. Demographics, clinical rating scales, and tremor parameters (RMS of angular velocity and angular displacement, peak magnitude, and frequency) were assessed before and during stimulation. Correlations with validated clinical rating scales were performed.

RESULTS

There were no statistically significant differences between groups in demographics, rating scales, or tremor parameters. During stimulation, significant reduction in RMS angular velocity (as percentage) in every axis and peak magnitude in axis (x-, y-) and UPDRS tremor score, were found with Tremor's glove compared to the sham groups (p<0.05, each). Significant moderate correlations were observed between a percentage reduction of RMS angular velocity in every axis and UPDRS tremor scores. Mean duration of tremor reduction after stimulation was 107.78±104.15s. No serious adverse events were observed.

CONCLUSION

In this study, EMS-based Tremor's glove was effective in suppressing resting hand tremor in PD patients. Tremor's glove is light-weight with a good safety profile, making it a future potential therapeutic option for PD patients with medically refractory tremor.