Iris Reuter

Training of executive functions in Parkinson's disease

Cognitive disturbances are common in Parkinsons disease (PD). Examination of cognitive function often reveals deficits in executive functions, including maintenance and inhibition of attention, flexibility in thinking, and planning. The involvement of the dopaminergic system in cognitive executive functions has been suggested by numerous studies. The aim of the present study was to analyze the effect of cognitive training on cognitive performance of PD-patients (N=26). Half of the patients participated in a cognitive training regimen, while the other patients only received standard treatment. The outcome showed improved performance of the group with cognitive treatment in two executive tasks after the training period, while no improvement was seen in the standard-treatment group. The results indicate that specific training is required for improvement of executive functions, while general rehabilitation is not sufficient. Thus, PD-patients might benefit from a short-term cognitive executive function training program that is tailored to the individual patients needs.

Effects of a Flexibility and Relaxation Programme, Walking, and Nordic Walking on Parkinson's Disease

Symptoms of Parkinsons disease (PD) progress despite optimized medical treatment. The present study investigated the effects of a flexibility and relaxation programme, walking, and Nordic walking (NW) on walking speed, stride length, stride length variability, Parkinson-specific disability (UPDRS), and health-related quality of life (PDQ 39). 90 PD patients were randomly allocated to the 3 treatment groups. Patients participated in a 6-month study with 3 exercise sessions per week, each lasting 70 min. Assessment after completion of the training showed that pain was reduced in all groups, and balance and health-related quality of life were improved. Furthermore, walking, and Nordic walking improved stride length, gait variability, maximal walking speed, exercise capacity at submaximal level, and PD disease-specific disability on the UPDRS in addition. Nordic walking was superior to the flexibility and relaxation programme and walking in improving postural stability, stride length, gait pattern and gait variability. No significant injuries occurred during the training. All patients of the Nordic walking group continued Nordic walking after completing the study.

Efficacy of a multimodal cognitive rehabilitation including psychomotor and endurance training in Parkinson's disease.

Mild cognitive impairment, especially executive dysfunction might occur early in the course of Parkinsons disease. Cognitive training is thought to improve cognitive performance. However, transfer of improvements achieved in paper and pencil tests into daily life has been difficult. The aim of the current study was to investigate whether a multimodal cognitive rehabilitation programme including physical exercises might be more successful than cognitive training programmes without motor training. 240 PD-patients were included in the study and randomly allocated to three treatment arms, group A cognitive training, group B cognitive training and transfer training and group C cognitive training, transfer training and psychomotor and endurance training. The primary outcome measure was the ADAS-Cog. The secondary outcome measure was the SCOPA-Cog. Training was conducted for 4 weeks on a rehabilitation unit, followed by 6 months training at home. Caregivers received an education programme. The combination of cognitive training using paper and pencil and the computer, transfer training and physical training seems to have the greatest effect on cognitive function. Thus, patients of group C showed the greatest improvement on the ADAS-Cog and SCOPA-COG and were more likely to continue with the training programme after the study.

Transcranial sonography for diagnosis of Parkinson's disease

BackgroundIn idiopathic Parkinsons disease (IPD) transcranial sonography (TCS) represents an alternative diagnostic method to verify clinical diagnosis. Although the phenomenon of an increased echogenicity of the Substantia nigra (SN) is well known this method is still not widly used in the diagnostic workup. Until now reliability of this method is still a matter of debate, partly because data only existed from a few laboratories using the same ultrasound machine. Therefore our study was conducted to test the reliability of this method by using a different ultrasound device and examining a large population of control and IPD subjects by two examiners to calculate interobserver reliability.MethodIn this study echogenicity of SN was examined in 199 IPD patients and 201 control subjects. All individuals underwent a neurological assessment including Perdue pegboard test and Webster gait test. Using a Sonos 5500 ultrasound device area of SN was measured, echogenicity of raphe, red nuclei, thalamus, caudate and lenticular nuclei, width of third and lateral ventricle were documented.ResultsWe found a highly characteristic enlargement of the SN echogenic signal in IPD. The cut-off value for the SN area was established using a ROC curve with a sensitivity of 95% corresponding to an area of SN of 0.2 cm2 and was found to be equivalent to the cut-off values of other studies using different ultrasound devices.ConclusionsOur study shows that TCS is a reliable and highly sensitive tool for differentiation of IPD patients from individuals without CNS disorders.

Aging, Physical Activity, and Disease Prevention 2012

Although no amount of physical activity can stop the biological aging process, regular exercise can counteract some of the adverse physiological, psychological, and cognitive consequences of aging [1]. Age and physical inactivity are primary and secondary (indirect) risk factors for a long list of adverse chronic conditions [2, 3], whereas increasing physical activity from midlife to old age results in reduced rates of chronic disease and death [3, 4]. Our Call for Papers was driven by a growing body of evidence showing strong associations between physical inactivity and age-related chronic disease, as well as reductions in risks or incidence of chronic disease with exercise training [1]. Despite the overwhelming evidence for the role of physical activity in reducing the incidence of mortality, morbidity, and quality of life in chronic disease, a relatively small portion of the population are physically active worldwide [5] and even fewer older adults exercise regularly with sufficient intensity, duration, and frequency to receive optimal benefits for disease prevention [1]. Physical inactivity is especially prevalent in highly developed countries [5]. For this reason, more research is needed to understand and overcome barriers for habitual exercise and sport participation (see 3rd paper in this issue). A recent study ordered reasons for participating in exercise programs and found that social aspects followed by the intent to improve physical fitness and/or prevent chronic diseases ranked among the highest reasons in older adults. With the increasing number of elderly, especially in the highly developed countries, it is important, yet challenging, to offer attractive and accessible physical activity programs to elderly. Qualified supervision, medical evaluations, and evidence-based individualized exercise prescriptions are also important for older sedentary adults, particularly those with underlying cardiovascular disease [6]. Besides cardiovascular and metabolic disease prevention, physical activity might also help reduce the risk of dementia [7, 8] and maintain cognitive function [9]. Since the risk of dementia is strongly associated with age and the number of adults surviving to advanced age will increase markedly in the near future, preventive measures become increasingly important. In this context, there is even some evidence that biological aging of the brain might be slowed down and that brain areas most affected by the aging process might benefit most from regular exercise [10]. This special issue covers a wide array of topics on the aging and physical activity and their relationship to disease and disability prevention. The papers show how aging and physical activity are associated with disability, mortality, behavioral change, home-based counseling interventions, bone and connective tissue health, telomere biology, Parkinsons disease, diabetes, hypertension, cancer, inflammation, antioxidants, sleep apnea, and cognitive function. The first paper investigates the impact of physical activity on disability in Mexico and the USA The second paper focuses on the relationship between physical activity and mortality rates over a 7-year period in the UK The influence of aging on social cognitive characteristics associated with physical activity and whether improvements in psychosocial factors influence age-related declines in physical activity are discussed in the third paper. The fourth paper assessed the qualities of a counseling intervention on sustaining a physically active lifestyle. The authors of the fifth paper provide a review of the potential benefits of aerobic exercise training and whole-body vibration training on bone mineral density in older populations and discuss possible mechanisms for effects of each intervention. A review of the bone mineral density literature is also highlighted in the sixth paper, but with a focus on how it applies to physical performance and other components of body composition. The risk of osteoporosis is described in the seventh paper by assessing the relationship of physical activity, hip fractures, and disability from hip fractures. The eighth paper highlights the role of exercise on the prevention and treatment of osteoarthritis, whereas the ninth paper explains the benefits of both aerobic and resistance exercise training for patients with rheumatoid arthritis. The authors of the tenth paper show how physical and leisure activity can help counteract the association of wheelchair use and poor health perception. The eleventh papre describes the relationship between physical activity and telomere biology as it applies to age-related diseases and longevity. A flexibility and relaxation program is compared to regular walking versus a Nordic walking program in patients with Parkinsons disease in the twelfth paper. The authors of the thirteenth paper review the literature on resistance training and glucose tolerance with applications to diabetes risk in older adults and potential mechanisms of action. The fourteenth paper investigates the effects of aerobic exercise training on the formation of a signaling molecule that influences vascular tone known as eicosanoids. The fifteenth paper reviews the literature on the use of strength training as an intervention to offset some of the deleterious side effects of hormone therapy used by prostate and breast cancer patients. The sixteenth paper studied the role of specialized G-proteins that increase cAMP known as melanocortin 3 receptors on the anti-inflammatory process of resistance training. The antioxidant potential of Tai Chi training is explained in the seventeenth paper, and the last paper describes the role of cognitive function on lower-body physical performance in older African American women. Ben Hurley Iris Reuter

Botulinum-Neurotoxin in der Behandlung der Spastizität im Erwachsenenalter

Spasticity is one of the major causes of functional impairment in adults with lesions of the central nervous system. For instance, approximately 30% of post-stroke patients suffer from different degrees of spasticity with possible consecutive impairments. Numerous studies or meta-analyses showed that local injections of botulinum toxin in spastic muscles lead to dose-dependent reduction in muscle tone and improvement of passive movements (e. g. facilitated care), especially following repeated injections.However, country-specific regulations and patient-remote administration in German health care often do not allow adequate provision of this therapy. Thus, the present consensus statement based on the EBM analyses of the published international literature tries to highlight recent advances and the standard in the field of local spasticity treatment, aiming to facilitate communication between the decision makers and German reimbursement institutions in health care. Prior to initiation of BoNT-A injections, patient-oriented goals should be identified in a multiprofessional context to assure realistic goals for this specific treatment and patient expectations. In Germany for the treatment of focal spasticity following stroke three products have been approved: Botox® (Pharm Allergan, Ettlingen), Dysport® (Ipsen Pharma, Ettlingen) and Xeomin® (Merz Pharma, Frankfurt/Main). For all preparations safety has been repeatedly shown. Functional improvements have also been illustrated for selected patients concerning hand/arm function and gait. The dose per muscle and the selection of muscles to be injected have to be individualized according to the patients symptoms and should be accompanied by modern neurorehabilitative therapies such as redression or repetitive activation of the injected and antagonistic muscles.

Torticollis under cyclobenzaprine.

The muscle-relaxing 5-HT2 receptor antagonist cyclobenzaprine is structurally closely related to amitriptyline. It is widely used to treat patients presenting with back pain and fibromyalgia. Very rarely cyclobenzaprine toxicity can result in extrapyramidal symptoms, but occurrence of torticollis has not been reported so far. We report on a patient presenting with torticollis and myoclonic movements after treatment with cyclobenzaprine, who was successfully treated with intravenous biperiden. This case might be additional evidence for the necessity of appropriate dosage in case of liver impairment. Secondly there are possibly consequences as regards the therapy of motor side effects.

Nigrosome 1 visibility at susceptibility weighted 7T MRI—A dependable diagnostic marker for Parkinson's disease or merely an inconsistent, age-dependent imaging finding?

Background Visualisation of nigrosome 1, a substructure of the healthy substantia nigra, was restricted in susceptibility weighted MR imaging in almost all patients with Parkinsons disease studied so far. The purpose of this study was to determine the degree of visibility of this substructure in subjects without Parkinson’s disease and to examine the potential link between increasing brain iron accumulation with age and its detectability. Methods In 46 subjects (21 women, 25 men; 19 to 75 y; mean age: 44.5; SD: 15.6) examined with susceptibility weighted MR imaging at 7T visibility of nigrosome 1 was rated and classified. We assessed differences related to age and to signal intensities in the substantia nigra, red nucleus and putamen as correlates of the individual iron concentration. Results In 93% nigrosome 1was at least unilaterally clearly present. In 24% at least one-sided limited visibility was observed. Using predefined classification criteria the specificity of the visibility across all age groups reached approximately 94%. We found no correlation with increasing iron concentrations with age. Conclusion Aging with a related increase in iron concentration probably does not affect the visibility of nigrosome 1 at 7T SWI MRI. Our results support the role of this feature as a future differential diagnostic tool but further large-scale prospective studies are needed to better define the extent of a “limited visibility” to which an individual can be considered healthy.

One decade of oral anticoagulation in stroke patients: Results from a large country-wide hospital-based registry

Background New evidence regarding stroke prevention in atrial fibrillation has been published. Implementing knowledge into clinical practice remains challenging. Aims To investigate oral anticoagulants in stroke patients documented in a nationwide registry. Methods The database is an obligatory federal-state-wide hospital-based registry that covers more than 95% of all ischemic strokes, transient ischemic attacks and intracerebral hemorrhages in a community of more than six million inhabitants (Hesse/Germany). We analyzed oral anticoagulants prescribed on discharge in patients with stroke or transient ischemic attack during 2006–2015. Results From 2006 to 2015, we annually selected median 20,895 patients. From 2006 to 2015, the proportion of patients treated with oral anticoagulants increased (9.8% to 24%). The annual proportion of patients with atrial fibrillation remained constant (median: 23%). In atrial fibrillation patients treated with oral anticoagulants, the age increased (median 2008/2009: 76.9 years vs. 2014/2015 79.4 years). The percentage of treated individuals in atrial fibrillation increased dramatically (2006: 30.1% to 2015: 74.5%); in 2015, 30.8% of these patients received vitamin K antagonists and 70.2% new oral anticoagulants. Independent factors associated with new oral anticoagulants therapy were a previous medication with new oral anticoagulants and a treatment on stroke unit. Between new oral anticoagulants- and vitamin K antagonists-treated patients (2015), no differences in age were noted (both mean: 79.4 years). Conclusions The new oral anticoagulants availability enhanced a general trend treating more target patients with oral anticoagulants.

What is the value of fibre-endoscopic evaluation of swallowing (FEES) in neurological patients? A cross-sectional hospital-based registry study

Objectives Fibre-endoscopic evaluation of swallowing (FEES) to detect dysphagia is gaining more and more importance as a diagnostic tool. Therefore, we have investigated the impact of FEES in neurological patients in a clinical setting. Design Cross-sectional hospital-based registry. Setting Primary acute care in a neurological department of a German university hospital. Participants 241patients with various neurological diseases who underwent FEES procedure. Primary and secondary outcome measures Dysphagia and related comorbidities. Results 267 FEES were performed in 241 patients with various neurological diagnoses. Dysphagia was diagnosed in 68.9% of the patients. In only 33.1% of the patients, appropriate oral diet was chosen prior to FEES. A relevant dysphagia occurred more often in patients with structural brain lesions (83.1% vs 65.3%, P=0.001), patients with dysphagia had a longer hospitalisation (median 18 (IQR 12–30) vs 15 days (IQR 9.75–22.75), P=0.005) and had a higher mortality (8.4% vs 1.3%, P=0.041). When the oral diet was changed, we observed a lower pneumonia rate (36% vs 50%, P=0.051) and a lower mortality (3.7% vs 11.3%, P=0.043) in comparison to no change of oral diet. A restriction of oral diet was identified more often in older patients (median 75 years (IQR 66.3–82 years) vs median 72 years (IQR 60–79 years), P=0.01) and in patients with structural brain lesions (86.8% vs 73.1%, P=0.05). Conclusion On clinical investigation, dysphagia was misjudged for the majority of the patients. FEES might help to compensate this drawback, revising the diet regime in nearly 70% of the patients.