Bettina Möller

Alexithymia—an independent risk factor for impulsive‐compulsive disorders in Parkinson's disease

Impulsive‐compulsive disorders (ICDs) are frequent side effects of dopaminergic medication in Parkinsons disease (PD). Alexithymia, a personality trait characterized by difficulties identifying and describing feelings and an externally oriented thinking style, has been linked to various impulse‐control problems in the general population. In PD, the prevalence of alexithymia is approximately twice as high as in the general population. However, whether alexithymia is associated with ICDs in PD is currently unknown. We examined the relationship between self‐reported ICDs and alexithymia in a sample of 91 PD patients (89 on dopaminergic medication). Additional self‐report measures assessed impulsivity, depression, anxiety, behavioral inhibition/approach, and emotion‐regulation strategies. We observed that alexithymia, and particularly difficulty identifying feelings and difficulty describing feelings, was significantly correlated with ICDs, even when controlling for impulsivity, anxiety, and depression. In addition, a group analysis revealed that PD patients with clinical and moderate levels of alexithymia had significantly more ICDs than non‐alexithymic patients, suggesting that even moderately high alexithymia levels increase the risk for ICDs in PD. Our results identify alexithymia as an independent risk factor for ICDs in PD. Thus, the inclusion of alexithymia in the neuropsychiatric assessment of patients with PD may help identify patients at risk for ICDs.

Comparing the Fullerton Advanced Balance Scale With the Mini-BESTest and Berg Balance Scale to Assess Postural Control in Patients With Parkinson Disease

OBJECTIVES To validate the Fullerton Advanced Balance (FAB) Scale for patients with idiopathic Parkinson disease (PD); and to compare the FAB Scale with the Mini-Balance Evaluation Systems Test (Mini-BESTest) and Berg Balance Scale (BBS). DESIGN Observational study to assess concurrent validity, test-retest, and interrater reliability of the FAB Scale in patients with PD and to compare the distribution of the scale with the Mini-BESTest and BBS. SETTING University hospital in an urban community. PARTICIPANTS Patients with idiopathic PD (N=85; Hoehn and Yahr stages 1-4). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FAB Scale, Mini-BESTest, BBS, timed Up and Go test, Unified Parkinsons Disease Rating Scale, and visual analog scale. RESULTS Interrater (3 raters) and test-retest (3±1 d) reliability were high for all scales (ICCs≥.95). The FAB Scale was highly correlated with the Mini-BESTest (Spearman ρ=.87) and timed Up and Go test item of the Mini-BESTest (Spearman ρ=.83). In contrast with the BBS, the FAB Scale and Mini-BESTest have only minimal ceiling effects. The FAB Scale demonstrated the most symmetric distribution when compared with the Mini-BESTest and BBS (skewness: FAB scale: -.54; Mini-BESTest: -1.07; BBS: -2.14). CONCLUSIONS The FAB Scale is a valid and reliable tool to assess postural control in patients with PD. No ceiling effect was noted for the FAB Scale. Although the items of the FAB Scale are more detailed when compared with the Mini-BESTest, interrater and test-retest reliability were excellent. The scale is a promising tool to detect small changes of the postural control system in individuals with PD.

Comparison of the Fullerton Advanced Balance Scale, Mini-BESTest, and Berg Balance Scale to Predict Falls in Parkinson Disease

Background The correct identification of patients with Parkinson disease (PD) at risk for falling is important to initiate appropriate treatment early. Objective This study compared the Fullerton Advanced Balance (FAB) scale with the Mini-Balance Evaluation Systems Test (Mini-BESTest) and Berg Balance Scale (BBS) to identify individuals with PD at risk for falls and to analyze which of the items of the scales best predict future falls. Design This was a prospective study to assess predictive criterion-related validity. Setting The study was conducted at a university hospital in an urban community. Patients Eighty-five patients with idiopathic PD (Hoehn and Yahr stages: 1–4) participated in the study. Measurements Measures were number of falls (assessed prospectively over 6 months), FAB scale, Mini-BESTest, BBS, and Unified Parkinsons Disease Rating Scale. Results The FAB scale, Mini-BESTest, and BBS showed similar accuracy to predict future falls, with values for area under the curve (AUC) of the receiver operating characteristic (ROC) curve of 0.68, 0.65, and 0.69, respectively. A model combining the items “tandem stance,” “rise to toes,” “one-leg stance,” “compensatory stepping backward,” “turning,” and “placing alternate foot on stool” had an AUC of 0.84 of the ROC curve. Limitations There was a dropout rate of 19/85 participants. Conclusions The FAB scale, Mini-BESTest, and BBS provide moderate capacity to predict “fallers” (people with one or more falls) from “nonfallers.” Only some items of the 3 scales contribute to the detection of future falls. Clinicians should particularly focus on the item “tandem stance” along with the items “one-leg stance,” “rise to toes,” “compensatory stepping backward,” “turning 360°,” and “placing foot on stool” when analyzing postural control deficits related to fall risk. Future research should analyze whether balance training including the aforementioned items is effective in reducing fall risk.

Influence of subthalamic deep brain stimulation versus levodopa on motor perseverations in Parkinson's disease

Patients with Parkinsons disease (PD) show impairment in generating random motor sequences reflecting a higher order motor deficit in set‐shifting and suppression of perseverative behavior. The impact of deep brain stimulation (DBS) of the subthalamic nucleus (STN) on motor perseverations has not yet been elucidated. In 35 patients with PD, we evaluated the effect of STN‐DBS and levodopa on motor perseverations using the Vienna perseveration task. The task was performed 6 months after implantation of stimulation electrodes in the following three conditions: Stimulation off/medication off (Stim OFF/Med OFF), Stim ON/Med OFF, and Stim OFF/Med ON. Perseverations were measured by redundancy of second order (R2) with higher values indicating more severe perseverations. ANCOVA analysis revealed that influence of STN‐DBS on R2 significantly depended on R2 severity during Stim OFF/Med OFF (F = 4.69, P = 0.035). Accordingly, we classified patients with PD into two groups based on the R2 value during off treatment. In patients with mild perseveration (R2 < 35) neither STN‐DBS nor levodopa changed perseverations. By contrast, in patients with severe perseveration (R2 > 35), STN‐DBS significantly reduced R2 by 9.7 ± 2.6 (P < 0.001) whereas levodopa had no impact (R2 reduction 3.7 ± 1.6, P = 0.081). This demonstrates that STN‐DBS, by reducing motor perseveration, influences higher order aspects of motor behavior of patients with PD.

Functional impact of different muscle localization techniques for Botulinum neurotoxin A injections in clinical routine management of post-stroke spasticity

ABSTRACT Background: Treatment options for spasticity include intramuscular botulinum neurotoxin A (BoNT-A) injections. Both ultrasound (US) or electromyographic (EMG) guided BoNT-A injections are employed to isolate muscles. To date, most studies have included patients naïve to BoNT-A or following a prolonged wash out phase. Objective: To determine the impact of US/EMG guided BoNT-A injections on function in outpatients with spasticity receiving an established re-injection regime. Methods: Thirty patients post-stroke were investigated in a single-blinded, randomized controlled trial using a cross-over design for the EMG and US and a parallel design for the control group. The Modified Ashworth (MAS), Disability Assessment (DAS), Quality of Life (EQ-5D), self-rating scale and Barthel Index were assessed pre- and post-BoNT-A injections of upper limb muscles by a to the injection technique blinded person. Results: MAS improved in arm, finger and upper limb 4 weeks after BoNT-A treatment. The improvement showed no significant differences between the three injection techniques. Barthel Index, DAS and EQ-5D remained unchanged in all groups. Conclusions: This pilot study questions the impact of the instrumental guided injection techniques on everyday functionality in a routine clinical setting with established re-injection intervals. Larger trials are warranted with patients who are under long-term treatment on a regular basis.

SP 7. How to address the poor treatment acceptance for deep brain stimulation in Parkinson’s disease

Question Deep Brain stimulation (DBS) is a widely established, effective and well-tolerated treatment for Parkinson’s disease (PD). The patients’ way to receive this treatment usually consists of two steps: first, general neurologists refer them to a specialized DBS center where they undergo further diagnostic assessment and the final decision for or against this treatment is made. Electronic tools are available to support general neurologists in the selection of DBS candidates. Nevertheless, even after being preselected as an appropriate candidate, the majority of patients refused to be referred to a DBS center (Wachter et al., J Neurol 2011;258:641–646). Patients and methods Two projects were initiated to increase the treatment acceptance of DBS for PD: (A) A collaboration of 20 general neurologists and two movement disorder specialists at the University Hospital Dusseldorf was established. (B) 51 general neurologists located all over Germany were trained to use the electronic preselection tool STIMULUS and were handed out newly developed information materials. In both projects, appropriate DBS candidates were preselected. Their acceptance or refusal to undergo further diagnostic assessment at a DBS center was documented within a 16 months follow-up period. Further, several clinical characteristics and details of the patient briefing were collected and analyzed to identify factors which were predictive for patients’ decisions. Results (A) 912 PD patients were examined by the movement disorder specialist together with the general neurologist. In 92 cases (10.1%), a referral to undergo further diagnostic assessment at the University Hospital Dusseldorf was recommended. Within 16 months, 69 (70.4%) of those patients showed up in the specialized DBS center. (B) 264 patients were identified as appropriate candidates for DBS, using the electronic preselection tool STIMULUS and 114 (43.2%) had accepted to be referred to a DBS center within a 16 month follow-up period. The patients’ decisions were significantly influenced by their age, their classification as an akinetic-rigid type and when mentioning a potential reduction of dopaminergic side effects as well as the optimal time frame for DBS during the clarification talk. Conclusion Consultation visits by movement disorder specialists in collaboration with general neurologists substantially improved the treatment acceptance of PD patients for DBS. A training of general neurologists in combination with adequate information material might be a low-cost and effective alternative option. Both findings indicate the importance of a clarification talk to be crucial in order to increase the treatment acceptance for DBS. This assumption is supported by the talks’ topics side effects of dopaminergic medication and optimal time frame which were significantly related to a higher rate of acceptance if mentioned.