Parkinson's disease and osteoporosis

Metallic nanomaterials in Parkinson's disease: a transformative approach for early detection and targeted therapy

Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by substantial loss of dopaminergic neurons in the substantia nigra, leading to both motor and non-motor symptoms that significantly impact quality of life. The prevalence of PD is expected to increase with the aging population, affecting millions globally. Current detection techniques, including clinical assays and neuroimaging, lack the sensitivity and specificity to sense PD in its earliest stages. Despite extensive research, there is no cure for PD, and available treatments primarily focus on symptomatic relief rather than halting disease progression. Conventional treatments, such as levodopa and dopamine agonists, provide limited and often temporary relief, with long-term use associated with significant side effects and diminished efficacy. Nanotechnology, particularly the use of metallic-based nanomaterials (MNMs), offers a promising approach to overcome these limitations. MNMs, due to their unique physicochemical properties, can be engineered to target specific cellular and molecular mechanisms involved in PD. These MNMs can improve drug delivery, enhance imaging and biosensing techniques, and provide neuroprotective effects. For example, gold and silver nanoparticles have shown potential in crossing the blood-brain barrier, providing real-time imaging for early diagnosis and delivering therapeutic agents directly to the affected neurons. This review aims to reveal the current advancements in the use of MNMs for the detection and treatment of PD. It will provide a comprehensive overview of the limitations of conventional detection techniques and therapies, followed by a detailed discussion on how nanotechnology can address these challenges. The review will also highlight recent preclinical research and examine the potential toxicity of MNMs. By emphasizing the potential of MNMs, this review article aims to underscore the transformative impact of nanotechnology in revolutionizing the detection and treatment of PD.

Surgery for Degenerative Spinal Pathologies in Parkinson's Patients: Low Surgical Benefits for High Risks

OBJECTIVE

Lumbar disc herniation, canal stenosis, and cervicarthrosis are degenerative spinal pathologies frequently observed in the aging population of patients with Parkinson disease (PD). Spinal surgery in PD patients remains risky with uncertain functional results. The main issue is to determine whether a surgical procedure should be performed on PD patients with common degenerative spinal pathologies.

METHODS

Between 2017 and 2021, 38 PD patients were identified. Data on patient demographics was collected with outcome measures including neurological function, complications, and survival rates.

RESULTS

The median age was 70.7 years, and the median overall survival (OS) time after spinal surgery was 7 years (standard deviation [SD] 0.8). The mean follow-up time was 4.1 years. Thirteen patients (34.2%) died during the follow-up period with a median OS of 3 years. Among the 38 patients operated on: 10 (26.3%) benefited from instrumented surgery (cervicarthrosis or one-level fusion). Instrumented surgery confers a significantly lower median OS: 2.97 years versus 6.99 years for other patients (P = 0.007). The functional results of surgery regardless of type were generally poor: only 17/38 patients (44.7%) improved their walking perimeter and 20 (52.6%) reported that their pain had diminished. The two main prognosis factors with a significant link to better OS were a Hoehn and Yahr Scale ≤4 (P = 0.026), and an American Society of Anesthesiology score ≤2 (P < 0.008).

CONCLUSIONS

Noninstrumented or simple fusion level spinal surgery for patients with PD is fraught with numerous complications and produces very poor functional results. Nevertheless, a multidisciplinary perioperative approach for patients, with less invasive surgery whenever possible, provides the necessary conditions to ensure surgical success and avoid aggravating their fragile general condition.

Safety considerations for spinal surgery in patients with deep brain stimulation devices

PURPOSE

Deep brain stimulation (DBS) has been performed for various brain disorders. However, spinal surgery in patients with DBS was been approached with cautious trepidation due to risk of thermal brain injury and device damage from coagulation devices during surgery. This study presents the cases of successful spinal surgery performed after DBS implantation.

METHODS

We retrospectively reviewed the patients who received spinal surgery after DBS implantation between April 2001 and November 2022. We reviewed their demographic data, preoperative evaluations, and surgical strategies employed.

RESULTS

Among 348 patients who underwent DBS implantation, eight patients received spinal surgery. The methods used for diagnosing their spinal conditions varied: two cases of computed tomography (CT) myelogram, one case of CT scan with pre-DBS magnetic resonance imaging (MRI), one case of CT scan only, and four cases of post-DBS MRI. The location of the spinal surgery were one case of cervical spinal surgery, three cases of thoracolumbar spinal surgery, and four cases of lumbar spinal surgery. We followed diagnostic study guidelines and safety considerations tailored to each surgical step. Monopolar and bipolar coagulation devices were used when necessary. There were no cases of complications caused by spine surgery regarding DBS function or DBS implanted site.

CONCLUSION

Careful execution of surgical procedures, adherence to safety guidelines, and the use of MRI for diagnosis can ensure safe and successful spinal surgery in patients with DBS implants, minimizing the risk of damage to the DBS system and the brain.

Dopamine promotes osteogenic differentiation of PDLSCs by activating DRD1 and DRD2 during orthodontic tooth movement via ERK1/2 signaling pathway

Introduction

Orthodontic tooth movement (OTM) involves complex interactions between mechanical forces and periodontal tissue adaptation, mainly mediated by periodontal ligament cells, including periodontal ligament stem cells (PDLSCs), osteoblasts, and osteoclasts. Dopamine (DA), a neurotransmitter known for its critical role in bone metabolism, is investigated in this study for its potential to enhance osteogenic differentiation in PDLSCs, which are pivotal in OTM. This study examined the potential of DA to facilitate OTM by binding to DA receptors (D1R and D2R) and activating the ERK1/2 signaling pathway. We propose that DA's interaction with these receptors on PDLSCs could enhance osteogenic differentiation, thereby accelerating bone remodeling and reducing the duration of orthodontic treatments, which offering a novel approach to improve clinical outcomes in orthodontic care.

Methods

This study utilized a rat OTM model, micro-CT, histological analyses, and in vitro assays to investigate dopamine's effect on osteogenesis. PDLSCs were cultured and treated with DA, and cytotoxicity, osteogenic differentiation, gene and protein expression assessed.

Results

Dopamine administration significantly increased trabecular bone density and osteogenic marker expression in an OTM rat model. In vitro, DA at 10 nM optimally promoted human PDLSCs osteogenesis without affecting proliferation. Blocking DA receptors or inhibiting the ERK1/2 pathway attenuated these effects, underscoring the importance of dopaminergic signaling in tension-induced osteogenesis during OTM.

Conclusion

Taken together, our study reveals that local dopamine administration at a concentration of 10 nM not only enhances tension-induced osteogenesis in vivo but also significantly promotes osteogenic differentiation of PDLSCs in vitro through D1 and D2 receptor-mediated ERK1/2 signaling pathway activation.

Dietary quality and the gut microbiome in early-stage Parkinson's disease patients

BACKGROUND

The prevalence of Parkinson's disease (PD) has increased steadily with the increase of the elderly population. PD may influence dietary intake and quality, and the gut microbiome composition. The present study examined differences in dietary intake and quality between PD patients and controls according to sex. In addition, we assessed the gut microbiome composition.

METHODS

This cross-sectional study was conducted at A Medical Center, Seoul, South Korea. PD severity, swallowing function, olfactory function, and constipation status were examined by a skilled nurse. Dietary data were collected through a semi-quantitative food frequency questionnaire. Stool samples were subjected to microbiome analysis. To examine dietary quality, the Dietary Quality Index-International (DQI-I), Healthy Eating Index (HEI), Index of Nutritional Quality (INQ), Dietary Diversity Score (DDS), and Mediterranean Diet Score (MDS) were used. An independent t-test was used to determine differences between patients and controls. A chi-square test was used to examine frequency differences.

RESULTS

Dietary intake did not differ between the PD patient and control groups. Regarding dietary quality, the patients consumed more saturated fat compared to controls. Overall, the dietary differences between the groups were minor. The composition of the gut microbiome differed between PD patients and controls. Lactobacillus and Bifidobacterium genus were most abundant in PD patients. Prevotella VZCB and other Faecalibacterium were most abundant in controls.

CONCLUSIONS

Our results indicated that PD patients may experience gut microbiome change even in the early stage, while nutritional needs can be met when a balanced diet including various food groups are consumed.

An Isotonic Drink Containing Pacific Cod (Gadus macrocephalus) Processing Waste Collagen Hydrolysate for Bone and Cartilage Health

Malnutrition is one of the major factors of bone and cartilage disorders. Pacific cod (Gadus macrocephalus) processing waste is a cheap and highly promising source of bioactive substances, including collagen-derived peptides and amino acids, for bone and cartilage structure stabilization. The addition of these substances to a functional drink is one of the ways to achieve their fast intestinal absorption. Collagen hydrolysate was obtained via enzymatic hydrolysis, ultrafiltration, freeze-drying, and grinding to powder. The lyophilized hydrolysate was a light gray powder with high protein content (>90%), including collagen (about 85% of total protein) and a complete set of essential and non-essential amino acids. The hydrolysate had no observed adverse effect on human mesenchymal stem cell morphology, viability, or proliferation. The hydrolysate was applicable as a protein food supply or a structure-forming food component due to the presence of collagen fiber fragments. An isotonic fitness drink (osmolality 298.1 ± 2.1 mOsm/L) containing hydrolysate and vitamin C as a cofactor in collagen biosynthesis was prepared. The addition of the hydrolysate did not adversely affect its organoleptic parameters. The production of such functional foods and drinks is one of the beneficial ways of fish processing waste utilization.

Adult Spinal Deformity Correction in Patients with Parkinson Disease: Assessment of Surgical Complications, Reoperation, and Cost

BACKGROUND

Parkinson disease (PD) is a neurodegenerative disorder that manifests with postural instability and gait imbalance. Correction of spinal deformity in patients with PD presents unique challenges.

METHODS

The PearlDiver database was queried between 2010 and 2020 to identify adult patients with spinal deformity before undergoing deformity correction with posterior spinal fusion. Two cohorts were created representing patients with and without a preoperative diagnosis of PD. Outcome measures included reoperation rates, surgical technique, cost, surgical complications, and medical complications. Multivariable logistic regression adjusting for Charlson Comorbidity Index, age, gender, 3-column osteotomy, pelvic fixation, and number of levels fused was used to assess rates of reoperation and complications.

RESULTS

In total, 26,984 patients met the inclusion criteria and were retained for analysis. Of these patients, 725 had a diagnosis of PD before deformity correction. Patients with PD underwent higher rates of pelvic fixation (odds ratio [OR], 1.33; P < 0.001) and 3-column osteotomies (OR, 1.53; P < 0.001). On adjusted regression, patients with PD showed increased rates of reoperation at 1 year (OR, 1.37; P < 0.001), 5 years (OR, 1.32; P < 0.001), and overall (OR, 1.33; P < 0.001). Patients with PD also experienced an increased rate of medical complications within 30 days after deformity correction including deep venous thrombosis (OR, 1.60; P = 0.021), pneumonia (OR, 1.44; P = 0.039), and urinary tract infections (OR, 1.54; P < 0.001). Deformity correction in patients with PD was associated with higher 90-day cost (P = 0.007).

CONCLUSIONS

Patients with PD undergoing long fusion for deformity correction are at significantly increased risk of 30-day medical complications and revision procedures after 1 year, controlling for comorbidities, age, and invasiveness. Surgeons should consider the risk of complications, subsequent revision procedures, and increased cost.

Bone Mineral Density and the Risk of Parkinson's Disease in Postmenopausal Women

BACKGROUND

Whether bone mineral density (BMD) is related to the risk of Parkinson's disease (PD) is unclear.

OBJECTIVES

The objective of this study was to examine the association between BMD status and incident PD in postmenopausal women.

METHODS

We retrospectively examined a nationwide cohort of 272,604 women aged 66 years who participated in the 2009-2012 Korean national health screening for transitional ages. BMD was evaluated using dual-energy X-ray absorptiometry of the central bones. The use of antiosteoporosis medications (AOMs) was assessed. We performed multivariable Cox proportional hazards regression to evaluate the association between BMD and PD risk by calculating hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During the median follow-up of 7.7 years, 2,884 (1.1%) incident PD cases developed. After adjusting for confounding factors, lower BMD was associated with an increased risk of PD (P for trend <0.001). Individuals with osteoporosis had a 1.40-fold higher HR (1.40, 95% CI: 1.25-1.56) than those with a normal BMD. Sensitivity analyses suggested the associations robust to longer lag periods and further adjustment. These associations were prominent in individuals without AOM use before or after enrollment (P for interaction = 0.031 and 0.014). Increased risks of PD in individuals with osteopenia and osteoporosis who did not use AOMs were attenuated by the medication use during the follow-up period, regardless of previous AOM use.

CONCLUSIONS

Lower postmenopausal BMD and osteoporosis were associated with an increased risk of PD. In addition, this association could be mitigated using AOMs. Proper management of BMD in postmenopausal women may help prevent PD. © 2023 International Parkinson and Movement Disorder Society.

Association of serum uric acid levels with bone mineral density and the presence of osteoporosis in Chinese patients with Parkinson's disease: a cross-sectional study

INTRODUCTION

As the population ages, the incidence of osteoporosis among patients suffering from Parkinson's disease (PD) will surge continually, and the ensuing disability from falls is becoming a serious social burden. Due to its antioxidant properties, much literature has indicated the possible ability of serum uric acid (UA) to prevent ageing-related diseases caused by oxidative stress, including osteoporosis and PD. Therefore, this study was for exploring the connection of serum UA levels with bone mineral density (BMD) and the osteoporosis presence in Chinese PD patients.

MATERIALS AND METHODS

A cross-sectional design was used to statistically analyze 42 clinical parameters obtained from 135 patients with PD treated in Wuhan Tongji Hospital during 2020-2022. Multiple stepwise linear regression and multiple logistic regression analyses were constructed for identifying the association of serum UA levels with BMD as well as osteoporosis in PD patients, respectively. With receiver operative characteristic (ROC) curves, the optimal cutoff value was acquired for serum UA in the diagnosis of osteoporosis.

RESULTS

According to the regression analysis adjusted for confounders, serum UA levels in PD patients had positive correlation with BMD at each site and negative correlation with the presence of osteoporosis (P < 0.05 for all). ROC curves determined that the optimal cutoff value for UA to perform well in diagnosing osteoporosis in PD patients was 284.27 μmol/L (P < 0.001).

CONCLUSION

Relatively higher serum UA levels in the physiological range can work as a biomarker of higher BMD, and were strongly linked to lower prevalence of osteoporosis in Chinese PD patients.

Do Bone Mineral Density, Trabecular Bone Score, and Hip Structural Analysis Differ in Indian Men with Parkinson's Disease? A Case-Control Pilot Study from a Tertiary Center in Southern India

Objective

Parkinson's disease (PD) is a neurodegenerative condition that is characterized by bradykinesia, rigidity, and gait instability. Inherent to this condition is an increased predisposition to falls and fractures. Bone health in Parkinson's disease in India has not been studied thus far. This study aimed to assess the bone mineral density (BMD), trabecular bone score (TBS), and hip structural analysis (HSA) in Indian men with PD and compare them with matched controls.

Methodology

A case-control study done at a tertiary care center from southern India. Bone biochemistry, BMD, TBS, and HSA were assessed.

Results

Among 40 cases and 40 age, gender, and body mass index (BMI)-matched controls, there was no significant difference in BMD between both groups. The mean (SD) TBS at the lumbar spine [1.349 (0.090)] was significantly (P = 0.019) lower in men with PD as compared to matched controls [1.401 (0.089)]. Among the parameters of HSA, the buckling ratios were significantly higher at the femoral neck [11.8 (2.2) vs 9.4 (2.2); P = 0.001] and inter-trochanteric region [9.4 (2.1) vs 7.8 (1.4); P = 0.002] among cases as compared to matched controls. Vitamin D deficiency was significantly higher in this cohort of patients as was bone turnover marker indicating bone loss and a high bone turnover state.

Conclusion

A comprehensive bone health assessment comprising BMD, TBS, and HSA may be required to capture all aspects of bone strength in Indian men with PD as BMD assessment as a stand-alone tool may not suffice to obtain all information pertaining to fracture risk in these individuals.

Increased fracture risk in Parkinson's disease - An exploration of mechanisms and consequences for fracture prediction with FRAX

The relative contributions of factors such as muscle strength, falls risk and low bone mineral density (BMD) to increased fracture risk in Parkinson's Disease (PD) were examined in an analysis of 5212 community-dwelling women age 75 years or more recruited to a randomised, double-blind, placebo-controlled study of the oral bisphosphonate, clodronate. Similar number of PD and non-PD subjects received treatment. Each participant had measurements of hip and forearm BMD, muscle strength (hand grip strength and maximum isometric quadriceps strength), ability in the sit-to-stand test, and postural stability. Incident radiographic and/or surgically verified fractures, and deaths, were recorded over an average follow-up of 3.8 years. A diagnosis of PD was made if it was self-reported and appropriate medication was recorded at the study entry. 47 of the women (0.9 %) had a diagnosis of PD at baseline. They were of similar age to those without PD, but reported higher disability scores and lower quality of life. While BMD at the forearm and hip regions was lower in PD, this only reached statistical significance at the femoral neck (0.61 ± 0.12 vs 0.65 ± 0.12 g/cm², p = 0.037). Right hand grip strength was non-significantly lower in PD, but maximum right quadriceps strength was much reduced (96.9 ± 49.3 vs 126.3 ± 59.2 N, p = 0.003). Eleven (23.4 %) of the women with PD sustained 12 fractures, while 609 women (11.8 %) without PD sustained 742 osteoporotic fractures. The risk of osteoporotic fracture associated with PD was 2.24-fold higher in women with PD (Cox-regression HR 2.24, 95 % CI 1.23-4.06) and this remained high when adjusted for death as a competing risk (2.17, 95 % CI 1.17-4.01, p = 0.013). Following adjustment for femoral neck BMD, PD remained a significant predictor of fracture (HR 2.04, 1.12-3.70, p = 0.020). Entering PD as a risk variable using the rheumatoid arthritis input as a surrogate resulted in a reduction in PD as a FRAX-independent risk factor, particularly when BMD was included in FRAX (1.65, 95 % CI), but the relationship between PD and fracture risk appears to remain of clinical significance. The study suggests that PD may be an independent input in future iterations of FRAX, possibly due to non-skeletal components of risk such as reduced lower limb muscle strength. Introducing measures of muscle strength and performance in FRAX could also be considered.

Aggregated alpha-synuclein transcriptionally activates pro-inflammatory canonical and non-canonical NF-κB signaling pathways in peripheral monocytic cells

Parkinson's disease (PD) is a neurodegenerative disorder characterized by chronic neuroinflammation, loss of dopaminergic neurons in the substantia nigra, and in several cases accumulation of alpha-synuclein fibril (α-syn) containing Lewy-bodies (LBs). Peripheral inflammation may play a causal role in inducing and perpetuating neuroinflammation in PD and accumulation of fibrillar α-syn has been reported at several peripheral sites including the gut and liver. Peripheral fibrillar α-syn may induce activation of monocytes via recognition by toll-like receptors (TLRs) and stimulation of downstream NF-κB signaling; however, the specific mechanism by which this occurs is not defined. In this study we utilized the THP-1 monocytic cell line to model the peripheral transcriptional response to preformed fibrillar (PFF) α-syn. Compared to monomeric α-syn, PFF α-syn displays overt inflammatory gene upregulation and pathway activation including broad pan-TLR signaling pathway activation and increases in TNF and IL1B gene expression. Notably, the non-canonical NF-κB signaling pathway gene and PD genome wide association study (GWAS) candidate NFKB2 was upregulated. Additionally, non-canonical NF-κB activation-associated RANK and CD40 pathways were also upregulated. Transcriptional-phenotype analysis suggests PFFs induce transcriptional programs associated with differentiation of monocytes towards macrophages and osteoclasts via non-canonical NF-κB signaling as a potential mechanism in which myeloid/monocyte cells may contribute to peripheral inflammation and pathogenesis in PD.

Degenerative Spine Surgery in Patients with Parkinson Disease: A Systematic Review

BACKGROUND

Parkinson disease (PD) has been recognized as responsible for concurrent spinal disorders. Surgical correction may be necessary, but the complexity of such fragile patients may require specific considerations. We systematically reviewed the literature on degenerative spine surgery in patients with PD.

METHODS

PubMed, Scopus, Web of Science, and Cochrane were searched according to the PRISMA guidelines to include studies reporting clinical data of patients with PD undergoing degenerative spine surgery. Clinical characteristics, treatment protocols, and outcomes were analyzed.

RESULTS

We included 22 articles comprising 442 patients (61.5% female). Mean age was 66.9 ± 3.5 years (range, 41-83 years). Mean PD duration and modified Hoehn and Yahr stage were 4.46 ± 2.39 years and 2.3 ± 0.8, respectively. Operation types included fusion (55.3%) and decompression (41.6%). Mean operated spine levels were 6.0 ± 5.08. A total of 377 postoperative complications occurred in 34.6% patients, categorized into mechanical failure (58.0%), infection (15.1%), or neurologic (10.7%). Of patients, 31.8% required surgical revisions, with an average of 1.88 ± 1.03 revisions per patient. The average normalized presurgery, postsurgery, and final aggregate numeric patient outcome scores were 0.37 ± 0.13, 0.63 ± 0.18, and 0.61 ± 0.19, respectively, with a score of 0 and 1 representing the worst and best possible score.

CONCLUSIONS

Degenerative spine surgery in patients with PD is challenging, with complications and revisions occurring in up to a third of treated patients. Surgery should be offered when other treatment options have proved ineffective and is typically reserved for patients with myelopathy or significant disability. Successful outcomes depend on strong interdisciplinary support to control the movement disorder before and after surgery.

Complications, Readmissions, Revisions, and Patient-reported Outcomes in Patients With Parkinson Disease Undergoing Elective Spine Surgery: A Propensity-matched Analysis

STUDY DESIGN

Retrospective analysis on prospectively collected data.

OBJECTIVE

To determine the effectiveness of elective spine surgery in patients with Parkinson disease (PD).

BACKGROUND CONTEXT

PD has become increasingly prevalent in an aging population. While surgical treatment for degenerative spine pathology is often required in this population, previous literature has provided mixed results regarding its effectiveness.

METHODS

Data from the Quality Outcomes Database (QOD) was queried between April 2013 and January 2019. Three surgical groups were identified: (1) elective lumbar surgery, (2) elective cervical surgery for myelopathy, (3) elective cervical surgery for radiculopathy. Patients without PD were propensity matched against patients with PD in a 5:1 ratio without replacement based on American Society of Anesthesiology grade, arthrodesis, surgical approach, number of operated levels, age, and baseline Oswestry Disability Index, Numerical Rating Scale (NRS) extremity pain, NRS back pain, and EuroQol 5-Dimensions (EQ-5D). The mean difference was calculated for continuous outcomes (Oswestry Disability Index, NRS leg pain, NRS back pain, and EQ-5D at 3 and 12 mo after surgery) and the risk difference was calculated for binary outcomes (patient satisfaction, complications, readmission, reoperation, and mortality).

RESULTS

For the lumbar analysis, PD patients had a higher rate of reoperation at 12 months (risk difference=0.057, P =0.015) and lower mean EQ-5D score at 12 months (mean difference=-0.053, P =0.005) when compared with patients without PD. For the cervical myelopathy cohort, PD patients had lower NRS neck pain scores at 3 months (mean difference=-0.829, P =0.005) and lower patient satisfaction at 3 months (risk difference=-0.262, P =0.041) compared with patients without PD. For the cervical radiculopathy cohort, PD patients demonstrated a lower readmission rate at 3 months (risk difference=-0.045, P =0.014) compared with patients without PD.

CONCLUSION

For the matched analysis, in general, patients with and without PD had similar patient-reported outcomes and complication, readmission, and reoperation rates. These results demonstrate that a diagnosis of PD alone should not represent a major contraindication to elective spine surgery.

Postoperative Complication Rates After One-Level Cervical Spine Surgery in Patients with Parkinson Disease: A Database Study

OBJECTIVE

Parkinson disease (PD) is a risk factor for worse surgical outcomes. The degree to which PD affects outcomes in cervical spine surgery is not well understood. Therefore, we characterize rates of postoperative complications among patients with PD who undergo cervical spine surgery.

METHODS

Using the PearlDiver database, we identified patients who underwent 1-level anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), or discectomy/decompression with concomitant PD between 2011 and 2019. Patients with PD who underwent surgery and had 1 year follow-up were included. Complications 30, 60, and 90 days after surgery were identified and aggregated into body systems (e.g., respiratory and gastrointestinal). Comparison controls without concomitant PD who received cervical spine (C-spine) surgery were matched for age, sex, and comorbidities.

RESULTS

A total of 259,443 ACDFs, 30,929 PCFs, and 29,563 decompressions were identified. Of these procedures, 1117 were performed on patients with PD (0.35%). The highest 90-day complications rates in patients with PD were pulmonary and gastrointestinal related (6.05%) in those who received ACDF, neuro related (8.51%) in those who received PCF, and genitourinary related (8.76%) in those who received a decompression. Compared with patients without PD, postoperative complications rates were similar and not significantly different.

CONCLUSIONS

Patients with PD who receive ACDF have higher rates of pulmonary (6.05%), neurologic (5.24%), and psychiatric (3.23%) complications at 90 days. The differences did not reach statistical significance. This finding suggests that patients with PD do not experience higher rates of acute postoperative complications when undergoing 1-level cervical spine surgery.

No Vitamin D Deficiency in Patients with Parkinson’s Disease

Previous trials describe a decrease of vitamin D levels in patients with Parkinson’s disease and relationships to clinical disease severity. This case control study found higher but not significant 25-OH-vitamin D plasma levels in patients with Parkinson’s disease compared with age- and sex-matched controls and no associations to clinical parameters, such as rating scores of disease severity or assessments of cognitive function. A certain variability of vitamin D concentrations was observed in both cohorts, which were investigated during the same season. These outcomes put into perspective the emerging discussion on the importance of vitamin D in Parkinson’s disease. Our results warrant further confirmatory research with a strict matching design of patients and controls, which has not been done in previous investigations. We stress that this case control study does not allow any comment on the putative beneficial effects of vitamin D supplementation, ie, on bone mass or bone mineral density, in patients with Parkinson’s disease.

Risk Factors for Periprosthetic Femoral Fracture in Non-cemented Total Hip Arthroplasty Through the Direct Anterior Approach

Background: Although total hip arthroplasty (THA) performed through the direct anterior (DA) approach is frequently marketed as superior to other approaches, there are concerns about increased risks of intraoperative and early postoperative femoral fracture. Purpose: We sought to assess patient-specific and radiographic risk factors for intraoperative and early postoperative (90-day) periprosthetic femoral fracture (PPFx) following DA approach THA. Methods: We retrospectively reviewed 1107 consecutive, primary, non-cemented DA THAs, performed between April 2009 and January 2015, for intraoperative and early postoperative PPFx. Patients lost to follow-up before 90 days (63), cemented or hybrid THA (52), or early femoral failure for another indication (3) were excluded, yielding 989 hips for analysis. Demographic variables and patient comorbidities were analyzed as risk factors for PPFx. Continuous variables were initially compared with 1-way analysis of variance (ANOVA) and categorical variables with chi-square test. A demographic matched-paired radiographic analysis was performed for femoral stem canal fill and compared using univariate logistic regression. Results: The incidence of perioperative PPFx was 2.02%, including 10 intraoperative and 10 early postoperative fractures. Sustaining a postoperative PPFx was associated with being 70 years old or older with a body mass index (BMI) of less than 25, or with having either osteoporosis or Parkinson disease. Radiographs demonstrated that intraoperative PPFx was associated with stems that filled greater proximally rather than distally. Conclusion: Our cohort study found older age, age over 70 with BMI of less than 25, osteoporosis, and Parkinson disease were associated with increased risk for early postoperative PPFx following DA approach THA. Intraoperative fractures may occur with disproportionate proximal femoral canal fill. Further study can evaluate whether cemented femoral components may mitigate risk in these patient populations.

Vitamin D Status and Parkinson's Disease

Parkinson’s disease (PD) is a complex and progressive neurodegenerative disease, characterized by resting tremor, rigidity, slowness of movement, and postural instability. Furthermore, PD is associated with a wide spectrum of non-motor symptoms that add to overall disability. In recent years, some investigations, from basic science to clinical applications, have focused on the role of vitamin D in PD, often with controversial findings. Vitamin D has widespread effects on several biological processes in the central nervous system, including neurotransmission in dopaminergic neural circuits. Various studies have recorded lower levels of vitamin D in PD patients than in healthy controls. Low vitamin D status has also been correlated with the risk for PD and motor severity, whereas less is known about the effects vitamin D has on cognitive function and other non-motor symptoms. This review aims to better characterize the correlation between vitamin D and PD, clarify the role of vitamin D in PD prevention and treatment, and discuss avenues for future research in this field.

Consecutive Kummell's Disease Combined with Parkinson's Disease and Experienced Internal Fixation Failure: A Case Report and Literature Review

Background

The continuous occurrence of Kummell's disease is extremely rare in clinical practice, and its treatment is difficult. The study aimed to present a rare case of consecutive Kummell's disease combined with Parkinson's disease (PD) and experienced internal fixation failure.

Case presentation

A 69‐year‐old female patient had a history of PD for 10 years, and was treated by posterior decompression, fixation, and fusion because of Kummell's disease of T12 with neurological damage. The patient's back pain and lower limb pain were significantly improved after surgery. Twenty‐two months later, the patient was rehospitalized for Kummell's disease of L4 with neuropathic pain of left lower extremity. She received almost identical surgical procedures as T12 lesion, and the difference was no L4 vertebroplasty preformed due to the fact that the L4 vertebrae collapse was not obvious, the intravertebral vacuum cleft (IVC) range was small, and the pedicle screw fixation strength was high. The pain symptoms were significantly relieved after operation. Unfortunately, there was a complication of internal fixation failure that occurred a month later, and a revision operation was carried out.

Conclusion

Osteoporosis combined with PD may lead patients to become prone to consecutive Kummell's disease, and patients are prone to experience failure of internal fixation. Bone cement filling of vertebral IVC and effective support of anterior vertebral column are very important procedures to ensure the clinical efficacy of treating Kummell's disease.

A theoretical framework for addressing fear of falling avoidance behavior in Parkinson's disease

Postural instability in Parkinson's disease (PD) is associated with several downstream consequences that ultimately lead to a greater risk of falling. Among the prominent downstream consequences is fear of falling (FOF), which is both common and problematic in PD. It can lead to a vicious cycle of FOF avoidance behavior that results in more sedentary behavior, physical deconditioning, and weakening of already impaired balance systems. This, in turn, may make the person with PD more susceptible to a future fall even with benign daily tasks. While FOF activity avoidance can be adaptive (appropriate), it can also be maladaptive (inappropriate or exaggerated). When this adaptive and maladaptive FOF avoidance behavior is contextualized to gait/balance performance, it provides a theoretical framework that can be used by clinicians to match patterns of behavior to a concordant treatment approach. In the theoretical framework proposed in this perspective, four different patterns related to FOF avoidance behavior and gait/balance performance are suggested: appropriate avoiders, appropriate non-avoiders, inappropriate avoiders, and inappropriate non-avoiders. For each of the four FOF avoidance behavior patterns, this paper also provides suggested treatment focuses, approaches and recommendations.

Outcomes of Patients With Parkinson Disease Undergoing Cervical Spine Surgery for Radiculopathy and Myelopathy With Minimum 2-Year Follow-up

STUDY DESIGN

This was a retrospective cohort analysis.

OBJECTIVE

To identify the impact of Parkinson disease (PD) on 2-year postoperative outcomes following cervical spine surgery (CSS).

SUMMARY OF BACKGROUND DATA

(PD) patients are prone to spine malalignment and surgical interventions, yet little is known regarding outcomes of CSS among PD patients.

MATERIALS AND METHODS

All patients from the Statewide Planning and Research Cooperative System with cervical radiculopathy or myelopathy who underwent CSS were included; among these, those with PD were identified. PD and non-PD patients (n=64 each) were 1:1 propensity score-matched by age, sex, race, surgical approach, and Deyo-Charlson Comorbidity Index (DCCI). Demographics, hospital-related parameters, and adverse postoperative outcomes were compared between cohorts. Logistic regression identified predictive factors for outcomes.

RESULTS

Overall, patient demographics were comparable between cohorts, except that DCCI was higher in PD patients (1.28 vs. 0.67, P=0.028). PD patients had lengthier mean hospital stays than non-PD patients (6.4 vs. 4.1 d, P=0.046). PD patients also incurred comparable total hospital expenses ($69,565 vs. $57,388, P=0.248). Individual medical complication rates were comparable between cohorts; though PD patients had higher rates of postoperative altered mental status (4.7% vs. 0%, P=0.08) and acute renal failure (10.9% vs. 3.1%, P=0.084), these differences were not significant. Yet, PD patients experienced higher rates of overall medical complications (35.9% vs. 18.8%, P=0.029). PD patients had comparable rates of individual and overall surgical complications. The PD cohort underwent higher reoperation rates (15.6% vs. 7.8%, P=0.169) compared with non-PD patients, though this difference was not significant. Of note, PD was not a significant predictor of overall 2-year complications (odds ratio=1.57, P=0.268) or reoperations (odds ratio=2.03, P=0.251).

CONCLUSION

Overall medical complication rates were higher in patients with PD, while individual medical complications as well as surgical complication and reoperation rates after elective CSS were similar in patients with and without PD, though PD patients required longer hospital stays. Importantly, a baseline diagnosis of PD was not significantly associated with adverse two-year medical and surgical complications. This data may improve counseling and risk-stratification for PD patients before CSS.

LEVEL OF EVIDENCE

Level III.

Osteoporosis in Parkinson's Disease: Relevance of Distal Radius Dual-Energy X-Ray Absorptiometry (DXA) and Sarcopenia

Osteoporotic fractures are common in Parkinson's disease (PD). Standard dual-energy X-ray absorptiometry (DXA) measuring bone mineral density (BMD) at the femoral neck and lumbar spine (central sites) has suboptimal sensitivity in predicting fracture risk in the general population. An association between sarcopenia and osteoporosis in PD has not been studied. We compared BMD and osteoporosis prevalence in PD patients vs controls; determined the osteoporosis detection rates using central alone vs central plus distal radius DXA; and analyzed factors (in particular, sarcopenia) associated with osteoporosis. One hundred and fifty-six subjects (102 patients with PD, 54 spousal/sibling controls) underwent femoral neck-lumbar spine-distal radius DXA. Seventy-three patients and 46 controls were assessed for sarcopenia using whole-body DXA and handgrip strength. Patients underwent clinical and serum biochemical evaluations. PD patients had significantly lower body mass index compared to controls. After adjustment for possible confounders, distal radius BMD and T-scores were significantly lower in PD patients compared to controls, but not at the femoral neck/lumbar spine. With distal radius DXA, an additional 11.0% of patients were diagnosed with osteoporosis (32.0% to 43.0%), vs 3.7% in controls (33.3% to 37.0%) additionally diagnosed; this increase was largely driven by the markedly higher detection rate in female PD patients. Female gender (adjusted odds ratio [OR_adjusted] = 11.3, 95% confidence interval [CI]: 2.6-48.6) and sarcopenia (OR_adjusted = 8.4, 95% CI: 1.1-64.9) were independent predictors for osteoporosis in PD. Distal radius DXA increased osteoporosis detection, especially in female PD patients, suggesting that diagnostic protocols for osteoporosis in PD could be optimized. A close association between osteoporosis and sarcopenia was documented for the first time in PD, which has important implications for clinical management and future research.

Bone Mineral Density Loss in Parkinson's Disease: Impact of Clinical Subtypes

Background: This study aimed to compare the BMD status among the clinical subtypes of PD and healthy controls.Methods: Sixty patients with PD and 30 healthy age- and sex-matched controls were included in this study. The patients were divided into postural instability gait difficulty-dominant type (PIGDDT) group and tremor-dominant type (TDT) group based on the Unified Parkinson's Disease Rating Scale (UPDRS) score. BMD was measured using dual-energy X-ray absorptiometry scans in femoral and lumbar regions.Results: The T-scores in femoral and lumbar regions were similar in all groups. The prevalence of osteopenia was higher than the prevalence of osteoporosis in all three groups for femoral regions. The prevalence of osteoporosis in the intertrochanteric region and total femur in the PIGDDT group was higher than in the TDT group and controls. Our data showed a trend toward higher prevalence of osteoporosis in the PIGDDT group.Conclusion: The prevalence of osteopenia and osteoporosis may differ between clinical subtypes of PD and healthy controls. Osteopenia is more common than osteoporosis for all groups. The patients with PIGDDT of PD tended to have higher prevalence of osteoporosis, even at early stages of disease, compared to those with TDT and healthy controls.

Osteoporosis and the Risk of Parkinson's Disease: A Nationwide, Propensity Score-Matched, Longitudinal Follow-up Study

CONTEXT

Osteoporosis and Parkinson's disease (PD) often co-occur, and even patients with early-stage PD may have reduced bone-mineral density levels. This may imply that osteoporosis is associated with a higher risk of PD.

OBJECTIVES

This work aimed to determine whether patients with osteoporosis are at a higher risk of subsequently developing PD.

DESIGN AND SETTING

A retrospective cohort study was conducted using Taiwan's National Health Insurance Research Database.

PARTICIPANTS

A total of 23 495 individuals age 50 to 80 years who had osteoporosis between 2002 and 2006 were enrolled in the osteoporosis group. The comparison group comprised 23 495 propensity score-matched patients without osteoporosis. Their propensity scores were computed using a logistic regression model that included age, sex, comorbid conditions, and socioeconomic status.

RESULTS

The hazard ratio (HR) of PD for the osteoporosis group was 1.31 times larger than that of the comparison group (95% CI, 1.13-1.50, P < .001). The PD-free survival rate of the osteoporosis group was also significantly lower than that of the comparison group (P < .001). The analyses stratified by sex showed that women with osteoporosis appeared to have a higher magnitude of PD HR (HR 1.50; 95% CI, 1.27-1.77, P < .001) than their male counterparts (HR 1.23; 95% CI, 0.93-1.64, P = .15).

CONCLUSIONS

The present study's results suggest that osteoporosis is related to an increased risk of PD, especially among women.

Bone Mineral Density and Related Scores in Parkinson's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Parkinson's disease (PD) is the second most common degenerative neurologic disorder in older adults, and increasing attention has been paid to bone health in PD. Although several studies have shown that patients with PD have a lower bone mineral density (BMD) than do non-PD controls, there have been no systematic reviews in recent years.

METHODS

PubMed, Medline, and Web of Science were used to search relevant studies up to May 2020. BMD, BMD T score, and BMD Z score of patients with and without PD were statistically analyzed. Meta-analysis was conducted using Review Manager version 5.3.

RESULTS

This meta-analysis included 17 studies comprising 10,289 individuals. In the meta-analysis, adults with PD had lower total body, total hip, total radius, lumbar spine, total femur, femur neck, right-hand, and left-hand BMD than did non-PD controls. The T score of total body BMD, total hip BMD, total radius BMD, lumbar spine BMD, L1-L4 spine BMD, total femur BMD, and femur neck BMD in adults with PD were lower than those in non-PD controls. Futhermore, the Z score of total body BMD, total hip BMD, total radius BMD, lumbar spine BMD, L1-L4 spine BMD, and femur neck BMD was lower in adults with PD than in non-PD controls.

CONCLUSIONS

Patients with PD had a lower BMD, BMD T score, and BMD Z score compared with non-PD controls. Therefore, clinicians should routinely monitor BMD of patients with PD to prevent falling and fragility fractures in older adults and optimize BMD before surgical treatment of severe spinal deformity caused by PD.

Sheth M, Viswanath O, Urits I. Chronic Pain Treatment Strategies in Parkinson's Disease

Neurological disorders, including Parkinson's disease (PD), have increased in prevalence and are expected to further increase in the coming decades. In this regard, PD affects around 3% of the population by age 65 and up to 5% of people over the age of 85. PD is a widely described, physically and mentally disabling neurodegenerative disorder. One symptom often poorly recognized and under-treated by health care providers despite being reported as the most common non-motor symptom is the finding of chronic pain. Compared to the general population of similar age, PD patients suffer from a significantly higher level and prevalence of pain. The most common form of pain reported by Parkinson's patients is of musculoskeletal origin. One of the most used combination drugs for PD is Levodopa-Carbidopa, a dopamine precursor that is converted to dopamine by the action of a naturally occurring enzyme called DOPA decarboxylase. Pramipexole, a D2 dopamine agonist, and apomorphine, a dopamine agonist, and Rotigotine, a dopamine receptor agonist, have showed efficacy on PD-associated pain. Other treatments that have shown efficacy in treating pain of diverse etiologies are acetaminophen, Nonsteroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase-2 (COX-2) inhibitors. Opioids and opioid-like medications such as oxycodone, morphine, tramadol, and codeine are also commonly employed in treatment of chronic pain in PD. Other opioid related medications such as Tapentadol, a central-acting oral analgesic with combined opioid and noradrenergic properties, and Targinact, a combination of the opioid agonist oxycodone and the opioid antagonist naloxone have shown improvement in pain. Anticonvulsants such as gabapentin, pregabalin, lamotrigine, carbamazepine and tricyclic antidepressants (TCAs) can be trialed when attempting to manage chronic pain in PD. The selective serotonin and noradrenaline reuptake inhibitors (SNRIs) also possess pain relieving and antidepressant properties, but carry less of the risk of anticholinergic side effects seen in TCAs. Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been shown in multiple studies to be effective against various types of PD associated pain symptoms. Massage therapy (MT) is one of the most common forms of complementary and alternative medicine. Studies have shown that pressure applied during MT may stimulate vagal activity, promoting reduced anxiety and pain, as well as increasing levels of serotonin. In a survey study of PD patients, rehabilitative therapy and physical therapy were rated as the most effective for pain reduction, though with only temporary relief but these studies were uncontrolled. Yoga has been studied for patients with a wide array of neurological disorders. In summary, PD pathology is thought to have a modulating effect on pain sensation, which could amplify pain. This could help explain a portion of the higher incidence of chronic pain felt by PD patients. A treatment plan can be devised that may include dopaminergic agents, acetaminophen, NSAIDs, opioids, antidepressants, physical therapies, DBS and other options discussed in this review. A thorough assessment of patient history and physical examination should be made in patients with PD so chronic pain may be managed effectively.

Current Perspectives on Aerobic Exercise in People with Parkinson's Disease

Parkinson's disease (PD) is a progressive neurological disorder characterized by motor and non-motor symptoms for which only symptomatic treatments exist. Exercise is a widely studied complementary treatment option. Aerobic exercise, defined as continuous movement of the body's large muscles in a rhythmic manner for a sustained period that increases caloric requirements and aims at maintaining or improving physical fitness, appears promising. We performed both a scoping review and a systematic review on the generic and disease-specific health benefits of aerobic exercise for people with PD. We support this by a meta-analysis on the effects on physical fitness (VO2max), motor symptoms (Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor section), and health-related quality of life (39-item Parkinson's disease Questionnaire (PDQ-39)). Aerobic exercise has generic health benefits for people with PD, including a reduced incidence of cardiovascular disease, a lower mortality, and an improved bone health. Additionally, there is level 1 evidence that aerobic exercise improves physical fitness (VO2max) and attenuates motor symptoms (MDS-UPDRS motor section) in the off-medication state, although the long-term effects (beyond 6 months) remain unclear. Dosing the exercise matters: improvements appear to be greater after training at higher intensities compared with moderate intensities. We found insufficient evidence for a beneficial effect of aerobic exercise on health-related quality of life (PDQ-39) and conflicting results regarding non-motor symptoms. Compliance to exercise regimes is challenging for PD patients but may be improved by adding exergaming elements to the training program. Aerobic exercise seems a safe intervention for people with PD, although care must be taken to avoid falls in at-risk individuals. Further studies are needed to establish the long term of aerobic exercise, including a focus on non-motor symptoms and health-related quality of life.

The relationships of vitamin D, vitamin D receptor gene polymorphisms, and vitamin D supplementation with Parkinson's disease

In recent years, many studies have investigated the correlations between Parkinson's disease (PD) and vitamin D status, but the conclusion remains elusive. The present review focuses on the associations between PD and serum vitamin D levels by reviewing studies on the associations of PD with serum vitamin D levels and vitamin D receptor (VDR) gene polymorphisms from PubMed, Web of Science, Cochrane Library, and Embase databases. We found that PD patients have lower vitamin D levels than healthy controls and that the vitamin D concentrations are negatively correlated with PD risk and severity. Furthermore, higher vitamin D concentrations are linked to better cognitive function and mood in PD patients. Findings on the relationship between VDR gene polymorphisms and the risk of PD are inconsistent, but the FokI (C/T) polymorphism is significantly linked with PD. The occurrence of FokI (C/T) gene polymorphism may influence the risk, severity, and cognitive ability of PD patients, while also possibly influencing the effect of Vitamin D3 supplementation in PD patients. In view of the neuroprotective effects of vitamin D and the close association between vitamin D and dopaminergic neurotransmission, interventional prospective studies on vitamin D supplementation in PD patients should be conducted in the future.

Bone Mineral Density and Body Composition in Males with Motor Neuron Disease: A Study from Teaching Hospital in Southern Part of India

Background

Osteoporosis and sarcopenia are important aspects of motor neuron disease (MND). Individuals with amyotrophic lateral sclerosis (MND-ALS) have an increased risk of falls and fractures. Currently, the standard of care does not involve a routine assessment of bone mineral density (BMD) and body composition in these patients. We aimed to assess BMD, bone mineral parameters and body composition in men with MND and compared them with healthy controls.

Methods

Consecutive males between 50 and 80 years of age diagnosed as MND-ALS by revised El Escorial criteria and able to walk unassisted attending Neurology outpatient clinic were recruited into the study. Age, gender and body mass index (BMI) matched healthy controls were recruited from the local community. BMD and body composition were assessed by dual-energy x-ray absorptiometry (DXA). Bone mineral parameters and bone turnover markers (BTMs) were also assessed in them.

Results

A total of 30 subjects with MND-ALS and 33 controls were recruited. The mean age (years) was 59.2 in cases and 61.2 in controls. The mean BMD (g/cm²) between the two groups was similar; however, BTMs were significantly higher in the MND group (P < 0.05). Subjects with MND-ALS had significantly lower mean appendicular lean mass (ALM) (19.9 versus 22.4 kg; P = 0.007) and ALM corrected for BMI than the healthy control group (0.858 versus 0.934 kg/kg/m²; P = 0.034). Sarcopenic obesity (Percentage fat mass >27% + ALM/BMI <0.786 kg/kg/m²) was more prevalent in MND-ALS compared to controls (44.5% versus 16.7%; P = 0.03).

Conclusion

Although BMD was not significantly different between subjects with MND-ALS and healthy controls, BTMs were significantly higher in the MND group indicating a high bone turnover state. Sarcopenia and sarcopenic obesity were also more in MND-ALS group than controls. Routine assessment for bone health parameters and body composition indices may be included in management of the patients with MND.

Acute Postoperative Bilateral Vocal Fold Paralysis After Posterior Spinal Correction for Dropped Head Syndrome

BACKGROUND

Acute bilateral vocal fold paralysis is a life-threatening complication that can occur during spinal surgery but has almost exclusively occurred with anterior approaches. Bilateral vocal fold paralysis after posterior spinal surgery has been exceedingly rare.

CASE DESCRIPTION

We present a case of acute postoperative dyspnea due to vocal fold paralysis requiring intubation and surgical intervention after posterior spinal correction for the treatment of dropped head syndrome. The patient had had a previous diagnosis of atypical Parkinson disease but was later diagnosed with multiple system atrophy.

CONCLUSIONS

We suggest that multiple system atrophy can result in an increased risk of bilateral vocal fold paralysis during surgical intervention of dropped head syndrome. Thus, our report could be of interest for those who perform spinal surgery in patients with neurological conditions.

Parkinson's disease and the non-motor symptoms: hyposmia, weight loss, osteosarcopenia

Non-motor symptoms (NMSs) are common in Parkinson's disease (PD) and can precede, sometimes for several years. NMSs include, other than gastrointestinal symptoms like constipation and dysphagia, also hyposmia, weight loss and osteosarcopenia. These three NMSs seem to be inter-related and affect patients' health and quality of life. Unfortunately, patients with these symptoms usually are not initially seen by a neurologist, and by the time they are consulted, nearly ~ 80% of the dopaminergic neurons in the substantia nigra have died. To date, no guidelines exist for screening, assessment and management of NMSs in general. A better understanding of these specific NMSs, likely in the context of others, will make it possible to approach and optimise the treatment of the motor symptoms thereby enhancing the welfare of PD patients. Identifying the NMSs could be very helpful, and among them, hyposmia, weight loss and osteosarcopenia may play an important role in solving the limitations in the diagnosis of PD. A strict collaboration between general practitioners, clinicians, geriatricians and neurologists can be one approach towards the diagnosis of pre-PD. Waiting until the motor symptoms develop and the patient is finally visited by the neurologist could be too late, considering the catastrophic prognosis of the disease.

Risk factors of periprosthetic femoral fracture after total knee arthroplasty

INTRODUCTION AND OBJECTIVES

Periprosthetic fractures after primary knee arthroplasty has great importance in our environment due to the increase in their incidence and to the challenge they pose to the surgeon. Multiple factors have been associated with its production. The objective of the study was to identify the risk factors that could influence the appearance of these fractures, which of them are all modifiable and generate a probability prediction model based on these factors.

MATERIAL AND METHODS

Analytical, observational, retrospective, unpaired study of 38 cases of periprosthetic femoral knee fractures and 80 controls with knee prostheses. In total, 118 patients, 83 women and 35 men with a mean age of 72.49 years were included in the study. Sociodemographic data, medical history and drug consumption were collected, as well as those related to surgery. A univariate and bivariate analysis of the fracture determining factors was performed, using a logistic regression model to avoid confusion bias.

RESULTS

Of all the factors studied according to the logistic regression model, it was obtained that female sex (OR = 7.6), dementia (OR = 5), motor/parkinson's alteration (OR = 19.3) and femoral overcut Previous (OR = 8.6) were factors associated with the increased risk of this type of fractures.

CONCLUSIONS

This work allows us to conclude that there are risk factors such as female sex, dementia and parkinson's that increase the probability of periprosthetic fracture that are inherent to the patient and are not modifiable. However, there is any other totally modifiable that can be avoided by being demanding and thorough in the surgical technique, such as the anterior femoral overcut.

Fractures in the prodromal period of Parkinson disease

OBJECTIVE

To examine the association between fractures and Parkinson disease (PD) during the 5-year prodromal phase as compared to controls.

METHODS

We performed a population-based case-control study of Medicare beneficiaries in the United States from 2004 to 2009. We identified 89,632 incident PD cases and 117,760 comparable controls 66-90 years of age in 2009. PD case status was the outcome, and noncranial fracture the independent variable. We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for association between fracture and PD in yearly time intervals prior to PD diagnosis/control reference date, after adjusting for covariates.

RESULTS

There were 39,606 total fractures (25.4% cases, 14.3% controls) over the 5 years prior to the PD diagnosis/control reference date. PD was positively associated with fractures even after adjusting for age, sex, race/ethnicity, Charlson comorbidity index, alcohol use, tobacco use, and osteoporosis. The association between PD and fracture was evident at yearly time windows prior to PD diagnosis/control reference date. The association between PD and each type of fracture strengthened as the PD diagnosis/control reference date approached (all time interaction p values ≤0.02). Among beneficiaries with a mechanism of injury, the majority were attributed to falls (74.6% cases, 72.8% controls).

CONCLUSION

Fractures occur more commonly during the prodromal period of PD compared to controls, especially as diagnosis date approached, suggesting that patients with PD may experience unrecognized motor and nonmotor symptoms.

Bone Mineral Density and Risk of Osteoporotic Fractures in Women with Parkinson's Disease

Osteoporosis and Parkinson's disease (PD) are two important age-related diseases, which have an influence on pain, physical activity, disability, and mortality. The aim of this research was to study the parameters of bone mineral density (BMD), frequency, and 10-year probability of osteoporotic fractures (OFs) in females with Parkinson's disease (PD). We have examined 113 postmenopausal women aged 50-74 years old which were divided into 2 groups (I, control group (CG), n = 53 and II, subjects with PD, n = 60). Bone mineral density of lumbar spine, femoral neck, distal radius, and total body were measured, and quantity and localization of vertebral deformities were performed by the vertebral fracture assessment (VFA). Ten-year probability of OFs was assessed by Ukrainian version of FRAX®. It was established that BMD of lumbar spine, femoral neck, distal radius, and total body in PD women was reliably lower compared to CG. The frequency of OFs in PD subjects was higher compared to CG (51.7 and 11.3%, respectively) with prevalence of vertebral fractures (VFs) in women with PD (52.6% among all fractures). 47.4% of the females had combined VFs: 74.2% of VFs were in thoracic part of the spine and 73.7% were wedge ones. Ten-year probability of major OFs and hip fracture were higher in PD women compared to CG with and without BMD measurements. Inclusion of PD in the FRAX calculation increased the requirement of antiosteoporotic treatment from 5 to 28% (without additional examination) and increased the need of additional BMD measurement from 50 to 68%. Anterior/posterior vertebral height ratios (Th₈-Th₁₁) measured by VFA in PD females without confirmed vertebral deformities were lower compared to indices of CG. In conclusion, women with PD have lower BMD indices, higher rate of osteoporosis, and risk of future low-energy fractures that should be taken into account in the assessment of their osteoporosis risk and clinical management.

Parkinson's Disease and Symptomatic Osteoarthritis Are Independent Risk Factors of Falls in the Elderly

Objectives:

Deteriorating functionality and loss of mobility, resulting from Parkinson’s disease, may be worsened by osteoarthritis, which is the most common form of joint disease causing pain and functional impairment. We assessed the association between symptomatic hip or knee osteoarthritis, falls, and the ability to walk among patients with Parkinson’s disease compared to a control group.

Methods:

A total of 136 patients with Parkinson’s disease in Southern Estonia and 142 controls with an average age of 76.8 and 76.3 years, respectively, were enrolled in a retrospective case-control study. Information on falls and related fractures during the previous year was collected from the patients with Parkinson’s disease and controls. Covariates included gender, age, mobility, duration of Parkinson’s disease, and fractures.

Results:

Patients with Parkinson’s disease were at an increased risk of falls compared to the control group, and for the higher risk of fractures. Symptomatic knee or hip osteoarthritis was a significant independent predictor of falls in both patients with Parkinson’s disease and controls. The higher risk for fractures during the previous year was demonstrated in symptomatic osteoarthritis. Risk factors for falls included also female gender, use of sleep pills, and the inability to walk 500 m.

Conclusions:

Symptomatic hip and knee osteoarthritis are risk factors for falls and related fractures among the elderly population with and without Parkinson’s disease. The inability to walk 500 m could be used as a simple predictive factor for the increased risk of falls among elderly populations.

Bile acid abnormality induced by intestinal dysbiosis might explain lipid metabolism in Parkinson's disease

Intestinal dysbiosis refers to an imbalance in the intestinal flora. The concept of small intestinal bacterial overgrowth (SIBO), a condition of abnormal proliferation of the small intestine microbiota, has been proposed as a form of small intestine dysbiosis. In Parkinson's disease patients, weight loss and metabolic disorders such as lipid abnormalities are frequently encountered. This was a prospective investigation of the presence of SIBO using the lactulose breath test, Parkinson's disease symptoms, medications, abdominal symptoms, and blood data involving 39 Parkinson's disease patients. Of the 39 patients, 19 were positive for SIBO, 16 were negative, and 4 were equivocal. SIBO-positive patients had a significantly smaller dopaminergic drug load (dopamine replacement of Parkinson's disease drug potency) (P = 0.009) and significantly lower serum triglyceride (TG) (P = 0.024) and total bilirubin (P = 0.019) levels. No relationship was seen between the presence or absence of SIBO and motor or abdominal symptoms. The following hypothesis was developed with regard to the possibility that intestinal bacterial overgrowth has various effects that are exhibited via bile acid metabolism in Parkinson's disease patients. Serum bilirubin levels become higher as bilirubin metabolism declines with decreases in the intestinal bacteria. At the same time, bile acid is broken down due to increased intestinal bacteria, and lipid absorption decreases. This induces low serum TG levels and leads to weight loss. By a similar mechanism, there is less absorption of vitamin D as bile acid levels decrease, leading to osteoporosis and fractures. The possibility that some of the non-motor manifestations accompanying Parkinson's disease are caused by intestinal dysbiosis needs to be considered.

Relationship between 25-Hydroxyvitamin D, bone density, and Parkinson's disease symptoms

OBJECTIVES

Vitamin D deficiency is widespread in patients with Parkinson's disease (PD). Our aim was to determine whether serum vitamin D levels correlated with bone mineral density (BMD) and non-motor symptoms in patients with PD.

MATERIALS & METHODS

A consecutive series of 182 patients with PD and 185 healthy controls were included. Serum 25-hydroxyvitamin D (25[OH]D) levels were measured by immunoassay, while BMD of the lumbar spine and femoral neck was measured by dual-energy X-ray absorptiometry. Associations between serum vitamin D levels and clinical data were evaluated using partial correlation analysis.

RESULTS

Patients with PD had significantly lower serum 25(OH)D levels relative to healthy controls (49.75 ± 14.11 vs 43.40 ± 16.51, P < 0.001). Furthermore, PD patients with lower vitamin D levels had a significantly higher frequency of falls (P = 0.033) and insomnia (P = 0.015). They also had significantly higher scores for the Pittsburgh Sleep Quality Index (PSQI; P = 0.014), depression (P = 0.020), and anxiety (P = 0.009). Finally, patients with PD also had a significantly lower mean BMD of the lumbar spine (P = 0.011) and femoral neck (P < 0.001). After adjusting for age, sex, and body mass index, vitamin D levels significantly correlated with falls, insomnia, and scores for the PSQI, depression, and anxiety.

CONCLUSIONS

In patients with PD, vitamin D levels significantly correlated with falls and some non-motor symptoms. However, no associations were found between BMD and the serum 25(OH)D levels in patients with PD. Thus, vitamin D supplementation is a potential therapeutic for non-motor PD symptoms.

Bone loss caused by dopaminergic degeneration and levodopa treatment in Parkinson's disease model mice

Accumulating evidence have shown the association of Parkinson’s disease (PD) with osteoporosis. Bone loss in PD patients, considered to be multifactorial and a result of motor disfunction, is a hallmark symptom that causes immobility and decreased muscle strength, as well as malnutrition and medication. However, no known experimental evidence has been presented showing deleterious effects of anti-PD drugs on bone or involvement of dopaminergic degeneration in bone metabolism. Here, we show that osteoporosis associated with PD is caused by dopaminergic degeneration itself, with no deficit of motor activity, as well as treatment with levodopa, the current gold-standard medication for affected patients. Our findings show that neurotoxin-induced dopaminergic degeneration resulted in bone loss due to accelerated osteoclastogenesis and suppressed bone formation, which was associated with elevated prolactin. On the other hand, using an experimental model of postmenopausal osteoporosis, dopaminergic degeneration did not result in exacerbation of bone loss due to estrogen deficiency, but rather reduction of bone loss. Thus, this study provides evidence for the regulation of bone metabolism by the dopaminergic system through both gonadal steroid hormone-dependent and -independent functions, leading to possible early detection of osteoporosis development in individuals with PD.

Flexed Posture in Parkinson Disease: Associations With Nonmotor Impairments and Activity Limitations

BACKGROUND

People with Parkinson disease (PD) are twice as likely to develop flexed truncal posture as the general older population. Little is known about the mechanisms responsible beyond associations with age, axial motor impairments, and disease severity.

OBJECTIVE

The objective was to explore: (1) the associations of the nonmotor impairments of PD with flexed posture, and (2) the relationships of flexed posture with activity limitations.

DESIGN

This was a cross-sectional study.

METHODS

Seventy people with PD participated. Posture was measured in standing as the distance between the seventh cervical vertebra and a wall. Nonmotor impairments (cognition, depression, pain, fatigue, and proprioception) and activity performance (upper limb activity, bed transfers, respiratory function, and speech volume) were variously assessed using objective measures and self-report questionnaires. Univariate and multivariate regression analyses were performed to ascertain relationships between nonmotor impairments and truncal posture, and between truncal posture and activities.

RESULTS

Greater disease severity, greater axial impairment, poorer spinal proprioception, greater postural fatigue, and male sex were significantly associated with flexed truncal posture. The multivariate model containing these factors in addition to age explained 30% of the variability in flexed truncal posture, with male sex and axial motor impairment continuing to make independent contributions. A significant association was found between greater flexed truncal posture and poorer upper limb activity performance and respiratory function.

LIMITATIONS

A limitation to this study was that participants had mild-to-moderate disease severity.

CONCLUSIONS

Spinal proprioception and postural fatigue were the only nonmotor impairments to make significant contributions to flexed posture. Given the negative influence of flexed posture on upper limb activity and respiratory function, interventions targeting spinal proprioception and postural awareness should be considered for people with PD who might develop flexed posture.

Exercise for Parkinson's disease

Parkinson's disease is the second most common neurodegenerative disease with a prevalence rate of 1-2 per 1000 of the population worldwide. Pharmacological management is the mainstay of treatment. Despite optimal medication, motor impairment particularly balance and gait impairment persist leading to various degree of disability and reduced quality-of-life. The present review describes motor impairment including postural impairment, gait dysfunction, reduced muscle strength and aerobic capacity and falls. Physical therapy and complementary exercises have been proven to improve motor performance and functional mobility. Evidence on the efficacy of physical therapy and complementary exercises is presented in this review. These exercises include gait training with cues, gait training with treadmill, Nordic walking, brisk walking, balance training, virtual reality interventions, Tai Chi and dance. All these treatment interventions produce short-term beneficial effects and some interventions demonstrate long-term benefit. Gait training with treadmill enhance walking performance and the effects sustain for 3-6 months. Balance training improves balance, function and reduces fall rate, and these effects carry over to at least 12 months after training ended. Sustained Tai Chi for 6 months, dance therapy for 12 months, progressive resistive training for 24 months alleviates the PD motor symptoms, suggesting that they could slow down PD progression. Based on this evidence, individuals with PD are encouraged to sustain their training in order to improve/maintain their physical ability and to combat the progression of PD.

Management of fracture risk in Parkinson's: A revised algorithm and focused review of treatments

INTRODUCTION

Falls and fractures are a cause of substantial morbidity in Parkinson's. Despite an excess risk of both falls and osteoporosis, people with Parkinson's perceive that they are less likely to fracture than their peers, despite actually being at higher fracture risk. Recognising this increased risk, in 2014 we published an algorithm to guide management of fracture risk in this high-risk population. Recently, the National Osteoporosis Guideline Group (NOGG) published new guidance revising the 10 year fracture probability intervention thresholds for those over 70 years old to 20.3% for major osteoporotic fracture and 5.4% for hip fracture.

METHODS

In light of the new guidance, we have reappraised the use of two fracture prediction tools, Qfracture and FRAX, and have updated the algorithm to guide the management of bone health and fracture risk in people with Parkinson's.

RESULTS

We outline the treatment options available with particular consideration given to Parkinson specific factors that influence treatment choices.

CONCLUSION

This guidance is relevant to all healthcare specialist managing Parkinson's including neurologists, geriatricians and primary care practitioners.

Analysis of Relationships between Spinal Deformity and Walking Ability in Parkinson's Disease Patients

Introduction

This study aimed to determine impacts on walking ability of spinal deformity and imbalance as distinct from movement disorders in Parkinson's disease (PD).

Methods

Thirty-two patients (15 males, 17 females; mean age 72.5 years) were analyzed. Three, thirteen, eleven, and five were at Hoehn-Yahr stages I, II, III, and IV, respectively. In addition to various spinal imbalance and deformity classifications the following were assessed: Cobb angle (CA) for scoliosis, thoracic kyphosis (TK) at T2-12, thoracolumbar kyphosis(TLK) at T12-L2, lumbar lordosis(LL) at L1-S1, pelvic tilt(PT), pelvic incidence(PI), and sagittal vertical axis(SVA). The Timed Up and Go (TUG) test was used to measure walking ability. Patients were evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS) part III, and bone mineral density (BMD) scans.

Results

Nineteen patients (59%) had spinal deformity and imbalance within the following classifications: thoracic scoliosis, 1; thoracic kyphosis, 2; lumbar scoliosis, 15; Pisa syndrome, 3; camptocormia, 2. Mean values were 20.0° CA for scoliosis, 42.3° TK, 14.8° TLK, 26.7° LL, 20.8° PT, 48.8° PI, and 66.4 mm SVA. The mean TUG score was 13.9s. The UPDRS III mean was 36.6±24.5 points. Mean BMD was 0.856 g/cm² at lumbar L2-4 and 0.585 g/cm² at the femoral neck. UPDRS part III (P<0.001), LL (P<0.05), and femoral neck BMD (P<0.05) significantly correlated to TUG test results.

Conclusions

Distinct from the movement disorders of PD (UPDRS III), loss of normal LL and loss of BMD at the femoral neck were shown to be correlated with diminished walking ability (TUG test) in PD patients. When UPDRS improved in response to L-dopa, walking ability improved. In addition to any PD-specific interventions that contribute to the maintenance of ambulation, interventions specific to the restoration of LL, as well as early treatment for osteoporosis may positively affect HRQOL in PD.

Bone Mineral Density, TBS, and Body Composition Indexes in Ukrainian Men with Parkinson's Disease

INTRODUCTION

Current research studies demonstrate the changes of bone mineral density (BMD) in subjects with Parkinson's disease (PD); however, data about bone quality and body composition (BC) indexes are insufficient. The aim of the study was to assess the parameters of BMD, ВС, and trabecular bone score (TBS) in PD males.

MATERIALS AND METHODS

We performed a cross-sectional case-control research design and examined 76 males aged 50-77 years old, who were divided into two groups: first group including men without PD (n=38) and the second group including subjects with PD (n=38). Disease duration was at least 5 years; all PD participants were at levodopa therapy. BMD of lumbar spine, femoral neck, total femur, radius, and total body and TBS L l-L 4 were measured using the DXA method. Whole-body DXA measures were also used for the study of total, lean, and fat masses, skeletal muscle index (SMI), appendicular lean mass index (ALMI), and fat mass index (FMI).

RESULTS

Our study showed an increased incidence of osteoporosis and significantly lower total body BMD (respectively, 1.20 ± 0.13 and 1.26 ± 0.10 g/cm2, p=0.05), but not lumbar spine and femoral neck BMDs, and higher TBS value in PD men comparing to the control group (respectively, 1.33 ± 0.12 and 1.22 ± 0.18 un., p=0.005). Also, we established significantly decreased lower extremities BMD indexes, but not upper extremities, spine, and trunk BMDs in PD males. The femoral neck, proximal femur, and lower extremities BMD indexes in PD men were reliably lower at the side of predominance of clinical symptoms. Parameters of appendicular lean mass and ALMI in PD males were reliably higher, but fat mass values and FMI were lower compared to the control group in the absence of significant differences in lean mass values and SMI in weight-matched control.

CONCLUSION

Due to low BMD values, changes in BC are present in PD males, and appropriate screening and preventive strategies should be instigated to maintain bone health in PD subjects.